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.

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 Upgrade 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 THE PARTNER CARRIERS YOU WOULD LIKE TO SUBMIT YOUR UPGRADE REQUEST TO:*

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Participation Info:

Providers are required to verify the following information with Carriers prior to submitting an Upgrade Request. The phone numbers below are provided for your convenience. Please specifically ask the following from each Carrier:

• Contracted Effective Date
• Most Recent Effective Date
• Specific plans Provider is directly contracted with.

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Provider Info:

An Upgrade 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)

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.

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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Tax Identification Number(TIN):

Please provide the TIN data for this Provider.
LEGAL NAME OF ENTITY*

TAX IDENTIFICATION NUMBER (TIN)*

ENTITY TYPE*
---CooperativeCorporationLimited Liability Company (LLC)PartnershipSole ProprietorshipS CorporationProfessional Corporation (PC)Other

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

NAME OF PRIMARY ENTITY OWNER/OFFICER*

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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. An Upgrade Request is a request to be added to the Cooperative associated fee schedule. The Cooperative will do everything we can to help to achieve your upgrade, but Carriers reserve the right to restrict and deny requests based on their own criteria.
• Most Carriers restrict upgrades within a specific time frame. Upgrades requests within the restricted time period will not be submitted.

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!