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.
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:
Careington Provider Relations Team 1-800-441-0380 (option 8)
Cigna Provider Relations Team 1-800-244-6224
Connection Provider Relations Team 1-800-821-6136
DenteMax Provider Relations Team 1-800-752-1547
Guardian Provider Relations Team 1-800-890-4774
Principal Provider Relations Team 1-800-638-1959
Sun Life Provider Relations Team 1-800-434-2638
Zelis Provider Relations Team 1-800-878-7896
An Provider Application Request form must be submitted individually for each provider.
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.
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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 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.
Include any additional miscellaneous documents:(file types:gif|png|jpg|jpeg|pdf)
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.
• 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.
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!