INSURANCE MAXIMIZATION

Action Request Form

Practice Info:

PRACTICE NAME*

PRACTICE STATE*

—Please choose an option—IdahoNevadaNew MexicoPennsylvaniaTexasUtahWashingtonWyomingOther

NAME OF EMPLOYEE MANAGING DENTAL INSURANCE*

EMAIL OF EMPLOYEE MANAGING DENTAL INSURANCE*

PHONE NUMBER OF EMPLOYEE MANAGING DENTAL INSURANCE*

Provider Info:

A Provider Application Request form must be submitted individually for each Provider.

FIRST, MIDDLE, LAST NAME (Legal Name)*

SPECIALTY*

—Please choose an option—General DentistDental AnesthetistEndodontistOral Maxillofacial SurgeonOrthodontistPediatric DentistPeriodontistProsthodontist

Carriers Requested:

You may select multiple Carriers. Prior to submitting, please check the Carrier's availability in your state as well as the associated Carrier fee schedule.

PLEASE SELECT ALL THE PARTNER CARRIERS YOU WOULD LIKE TO REQUEST AN ACTION FOR:*

CareingtonDenteMaxDHA/Sun LifeGEHA/ConnectionGuardianHumanaPrincipalSolsticeZelis

Action(s) Requested:

You may select multiple Actions if needed.

PLEASE SELECT ALL THE ACTIONS YOU WOULD LIKE TO REQUEST:*

Provider ApplicationUpgrade RequestAdd LocationChange FormOther/Unsure

Locations Requested:

You may request multiple Locations. Please include the full address. If submitting over 5 locations, please simply list the number of locations, and we will confirm the addresses with you.

PLEASE ENTER ALL THE ADDRESSES YOU WOULD LIKE TO REQUEST AN ACTION FOR:*

Include any necessary notes, comments, or instructions:

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.
• Participating Practice must have signed and submitted an Associate Agreement prior to IFM requests.
• Provider, must be included in the original Associate Agreement with the Practice. If not included, Provider must sign and submit an Add Member Provider form 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.
• The Dental Cooperative acts within the SEC parameters of a Messenger Model. Carriers reserve the right to restrict and deny requests based on their own criteria.

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

Name of Authorized Agent (required)

Date Agreement Signed mm/dd/yyyy (required)

Once submitted you will receive an auto- confirmation email. After that, you will be contacted by our Insurance Maximization team within 3 business days with the next steps and/or processing status. Some requests may require additional information. If you have not been contacted within 5 business days of this email, please contact our insurance team at 801.456.0445. You will get a "Success!" message at the bottom of this form if it submits correctly.