INSURANCE FEE MAXIMIZATION

Principal: Contracted

REQUESTED ACTION:
---Fee Upgrade RequestAdd LocationChange Form

PRACTICE INFORMATION:
Practice Name (required)

Cooperative Account# (optional. Found on monthly mailed invoice.)

Name of Employee Managing Dental Insurance (required)

Email of Employee Managing Dental Insurance (required)

PROVIDER REQUESTING ACTION:
First Name of Dentist (required)

Middle Name of Dentist

Last Name of Dentist (required)

Specialty (required)
---General DentistDental AnesthetistEndodontistOral Maxillofacial SurgeonOrthodontistPediatric DentistPeriodontistProsthodontist

Most Recent Effective Date with Principal MM/DD/YYYY (required. Date found by calling 844-638-1959)

Is this Dentist a current paying Member of the Dental Cooperative? (required)
---YESNO

LOCATIONS OF REQUESTED ACTION:
Number of Locations requested for this action (required)
---12345678910111213141516171819202122232425+

*If more than 5 locations, do not fill out the Address info below:
Location 1 Address (Address, City, State, Zip)

Location 2 Address (Address, City, State, Zip)

Location 3 Address (Address, City, State, Zip)

Location 4 Address (Address, City, State, Zip)

Location 5 Address (Address, City, State, Zip)

TERMS AND CONDITIONS OF PARTICIPATION
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.
• A completed, signed, and submitted Associate Agreement to the Dental Cooperative is required for all participating Providers.
• Any Provider who has terminated their Dental Cooperative membership will have access to fee schedule resources terminated.
• The Dental Cooperative will inform Principal of membership termination and Principal 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.
• Additional program details and terms are available on your Associate Agreement.

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, the Information Request will be sent to our Director of Insurance Fee Maximization for verification. Once received and processed, you will receive an email with instructions for the next step.