INSURANCE FEE MAXIMIZATION

Initial Provider Data

Practice Info:

*required

PRACTICE NAME*

COOPERATIVE ACCOUNT# (optional. On monthly mailed invoice.)

NAME OF EMPLOYEE MANAGING DENTAL INSURANCE*

EMAIL OF EMPLOYEE MANAGING DENTAL INSURANCE*

Provider Info:

FIRST NAME*

MIDDLE NAME

LAST NAME*

PROVIDER EMAIL*

SPECIALTY*
---General DentistDental AnesthetistEndodontistOral Maxillofacial SurgeonOrthodontistPediatric DentistPeriodontistProsthodontist

DATE BEGAN PRACTICING DENTISTRY* mm/dd/yyyy

DATE BEGAN AT CURRENT PRACTICE* mm/dd/yyyy

PROVIDER IS A CURRENT PAYING MEMBER OF THE DENTAL COOPERATIVE*
---YesNoI Don't Know

Provider Licenses & Insurance:

PROVIDER'S NPI#*

STATE DENTAL LICENSE* (file types:gif|png|jpg|jpeg|pdf)

DEA CERTIFICATE* (file types:gif|png|jpg|jpeg|pdf)

MALPRACTICE INSURANCE DECLARATION PAGE* (file types:gif|png|jpg|jpeg|pdf)

W9 FOR EACH LOCATION* (file types:gif|png|jpg|jpeg|pdf)
Click to Download W9

CV/RESUME/WORK HISTORY* (file types:gif|png|jpg|jpeg|pdf)

CONTROLLED SUBSTANCE/PHARMACY LICENSE (file types:gif|png|jpg|jpeg|pdf)

Terms and Conditions of Participation:

INSURANCE FEE MAXIMIZATION PROVIDER AGREEMENT* (Must be signed by Provider. file types:gif|png|jpg|jpeg|pdf)
Click to download Provider Agreement

To qualify for Insurance Fee Maximization through the Dental Cooperative, Providers must meet the following criteria:
• Provider must be a current, paying member of the Dental Cooperative in good standing.
• Provider, if not a current Member and/or not included in the original Associate Agreement with the Practice, must sign and submit an Add Member Provider form prior to IFM requests.
• Participating Practice must have signed and submitted an Associate Agreement prior to IFM requests.
• Provider who has terminated their Dental Cooperative membership will have access to fee schedule resources terminated.
• The Dental Cooperative will inform Carriers of membership termination and Carriers will take appropriate action as their individual policies dictate, which may include but not limited to a downgrade of fee schedule, return to previous fee schedule prior to membership or upgrade, or change to a base fee schedule indicated by the carrier.
• Provider must sign and return Insurance Fee Maximization provider Agreement prior to any IFM requests.

I agree to the Terms and Condition of Participation in this Agreement.

Name of Authorized Agent (required)

Date Agreement Signed mm/dd/yyyy (required)

Signature of Authorized Agent (required)

Once submitted, we will verify your membership and information. Once verified, you will receive an email with instructions for the next step. Just hold tight until you receive the email.

Please confirm the form submits, sometimes it takes a minute to go through. You will get a "Success!" message at the bottom of this form if it submits correctly. IMPORTANT: IF YOU DO NOT RECEIVE A CONFIRMATION EMAIL THAT WE RECEIVED YOUR DATA WITHIN 4 BUSINESS DAYS, PLEASE CONTACT US!