Requests can only be submitted for current Dental Cooperative members. Please contact your local Area Director to add your Provider to the Dental Cooperative before submitting a request. Click here to find your local Area Director:

:: Select Your Area ::
Idaho
Nevada
New Mexico
Pennsylvania
Texas: West Texas
Utah: Central & Southern Utah
Utah: Northern Utah
Area Not Listed

IS THIS A NEW ASSOCIATE TO YOUR PRACTICE?*
---YesNo

FOR THIS NEW ASSOCIATE, HAVE YOU ALREADY SUBMITTED AN "INITIAL PROVIDER DATA" FORM?*
---YesNo

New Providers are required to submit an Initial Provider Data form. Please click here to complete the Initial Provider Data form prior to your request.

Practice Info:

*required

PRACTICE NAME*

PRACTICE STATE*
---ALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

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

NAME OF EMPLOYEE MANAGING DENTAL INSURANCE*

EMAIL OF EMPLOYEE MANAGING DENTAL INSURANCE*

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Provider Info:

FIRST NAME*

MIDDLE NAME

LAST NAME*

SPECIALTY*
---General DentistDental AnesthetistEndodontistOral Maxillofacial SurgeonOrthodontistPediatric DentistPeriodontistProsthodontist

PROVIDER EMAIL*

DATE BEGAN PRACTICING DENTISTRY* mm/dd/yyyy

DATE BEGAN AT CURRENT PRACTICE* mm/dd/yyyy

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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)

TOTAL NUMBER OF LOCATIONS PROVIDER PRACTICES*
---12345678910+10

PROVIDER W9 FOR EACH LOCATION* (1-10 Locations)(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)

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Include any additional miscellaneous documents:(file types:gif|png|jpg|jpeg|pdf)

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Include any necessary notes, comments, or instructions:

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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!