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. Found on your Summary of Benefits.)

NAME OF EMPLOYEE MANAGING DENTAL INSURANCE*

EMAIL OF EMPLOYEE MANAGING DENTAL INSURANCE*

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Carriers Requested:

An Provider Application Request must be submitted individually for each provider. You may select more than one Carrier request per Provider.
Select a Practice State in the Practice Info section to view the corresponding Carriers.

PLEASE SELECT ALL THE PARTNER CARRIERS YOU WOULD LIKE TO SUBMIT YOUR PROVIDER APPLICATION REQUEST TO:*

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Participation Info:

Only Providers NOT directly contracted with the selected Carriers should submit a Provider Application Request form. Use the phone numbers below if you need to verify if a Provider is already directly contracted:

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Provider Info:

An Provider Application Request form must be submitted individually for each provider.

FIRST NAME*

MIDDLE NAME

LAST NAME*

SPECIALTY*
---General DentistDental AnesthetistEndodontistOral Maxillofacial SurgeonOrthodontistPediatric DentistPeriodontistProsthodontist

PROVIDER EMAIL*

PROVIDER'S NPI#*

PROVIDER MALPRACTICE INSURANCE DECLARATION PAGE* (file types:gif|png|jpg|jpeg|pdf)
Request forms should not be submitted if the Provider's Malpractice Insurance is within 60 days of expiration. Please submit this request after the new Malpractice Insurance has been received.

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

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Provider License Data:

Please provide the most current license information for the Provider listed above.
Request forms should not be submitted if the Provider's Dental License is within 60 days of expiration. Please submit this request after the new Dental License has been received.

PROVIDER DENTAL LICENSE#*

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

DENTAL LICENSE EXPIRATION DATE* mm/dd/yyyy

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Provider DEA Certificate Data:

Please provide the most current DEA (Drug Enforcement Agency) certificate information for the Provider listed above.
Request forms should not be submitted if the Provider's DEA Certificate is within 60 days of expiration. Please submit this request after the new DEA Certificate has been received.

PROVIDER DEA CERTIFICATE #*

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

DEA CERTIFICATE EXPIRATION DATE* mm/dd/yyyy

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Include any necessary notes, comments, or instructions:

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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.
• 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)

Signature of Authorized Agent* (Draw/sign below)

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 5 BUSINESS DAYS, PLEASE CONTACT US!