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

Practice Info:

PRACTICE NAME*

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

NAME OF EMPLOYEE MANAGING DENTAL INSURANCE*

EMAIL OF EMPLOYEE MANAGING DENTAL INSURANCE*

COOPERATIVE ACCOUNT# (Optional. Found on your Summary of Benefits.)

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Provider Info:

A 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*

DOES THE PROVIDER HAVE A CAQH PROVIDER ID?*
---YESNO

PROVIDER DENTAL LICENSE#*

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

PROVIDER NPI#*

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Carriers Requested:

You may select multiple Carriers. The Practice State in the Practice Info section must be selected 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:

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

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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.
• 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)

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. 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 YOUR AREA DIRECTOR.