• 1. Start-Up
  • 2. Established Office
  • 3. Personal Q Only
  • 4. Reminder Email
  • Personal Questionnaire
  • Location Questionnaire

Location Questionnaire

This contains all the information various carriers will need about your practice. This should only be completed by one person per practice, per location.

Step 1 of 12 - Dental Office Information

8%

  • Dental office information

  • This must match the NAME written on the IRS form that assigned you your TIN ( you can find this on your IRS SS4 document).
  • This may be your practice name. If you wish to have your checks made payable to this name rather than your legal entity (if different), you must place this DBA on the top line of your W9.
  • This is what the carriers will put on their directory websites. Please make sure that you have received permission from your state to use this name prior to listing it for us to use on carrier applications.
  • This must match your W9 and your SS4 documents
  • This is a the Office/Group NPI number, most solo practices don't have this number. If you plan on participation with Blue Cross/Blue Shield and/or plan on hiring an associate in the future, you may wish to obtain an NPI2 number now. This doesn't replace your individual NPI1 number which you will continue to use
  • if you have not obtained one yet, enter zeroes in this field- we will not change an office number after applications have been submitted
  • Not required by carriers. Enter all zeros (0) if you do not have a fax or fax number
  • please have this email be your primary administrative email address, not your personal office email-it may be listed online
  • The contact person above will be referenced for insurance carrier communication and can be your administrative email address or your own if you wish to be the contact.
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  • Addresses

  • Physical Address of Office

  • The county in the state in which the practice resides. This is not the country.
    Mailing address should be where you wish to have all carrier correspondence, including payments, forwarded to. If you are not yet receiving mail at your practice location, please list the mailing address you wish the carriers to use after you are open. Only list your home address if you wish to have all carrier payments come to your home going forward.

  • Mailing Address of Office

    For insurance payment purposes

  • Remittance Address

    We need to know this for Colorado State Required Questions which are more expansive than other states.
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  • Hours

  • Mondays - Hours of Operation
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  • Tuesdays - Hours of Operation
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  • Wednesdays - Hours of Operation
  • :
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  • Thursdays - Hours of Operation
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  • Fridays - Hours of Operation
  • :
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  • Saturdays - Hours of Operation
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  • Sundays - Hours of Operation
  • :
  • :
  • If you are not yet open, please answer this with what you intend to have set up once you are open.
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  • About the office

  • Please enter a number from 0 to 50.
  • Please enter a number from 0 to 20.
    If you are not yet open, please answer with what will apply when you are open.
    Either by utilizing a digital chartless system or in any organized patient file system.
    To include staff
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  • Accessibility

    Includes entry, exam room and restroom
    No barriers to prevent a handicapped / disabled person from receiving a comprehensive exam / service
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  • Emergency Preparedness

  • How is a patient to reach you for an emergency and how does the office respond?
  • Example: "Answering service with call returned"
  • Date Format: MM slash DD slash YYYY
    If you are a startup, please contact local vendor for approximate shelf life of drug kit from opening day to answer the below questions. This is going to be an estimation for offices that are not yet open and is only required on a single carrier application.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
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  • CPR and XRays

  • Please enter a number less than or equal to 20.
  • Please enter a number from 0 to 20.
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  • Sterilization

    Please check with your own state on the requirements (if any) for your state.
  • One carrier requires this – please find a local vendor to list here and you may change this before opening

  • Instrument Sterilization Type(s)

  • Hand Piece Sterilization Type(s)

  • Additional Questions

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  • Operations

  • Additional practice information

  • Date Format: MM slash DD slash YYYY

  • Methods of Payment

    For Startups, please choose "No".
    For Startups, please choose "No".
    Workers comp contracts with various carriers in each state and will authorize with individual patients treatment in a dental office and reimburse the dentist. If you wish to treat these patients, choose "Yes". If they utilize a network, you would receive your in-network fees for any treatment done.
  • Please enter a number from 0 to 15.
  • Please enter a number less than or equal to 99.
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  • Services Offered Questions

  • Example- Dentrix, Eagle Soft, Open Dental, etc. If you are a startup and you have not yet chosen your system, please choose the system you are most likely to use.

  • Services Offered at This Location

  • If Endodontics Offered, Check All That Apply

  • If Periodontics Offered, Check All That Apply

  • If Restorative is Offered, Check All That Apply

  • If Oral Surgery is Offered, Check All That Apply

  • If Pedodontics is Offered, Check All That Apply

  • Type(s) of Anesthesia Employed

    Please only check if you DO NOT offer amalgam restorations at all
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  • Doctors, Hygenists & Office Personnel at Location

  • Doctors at the Location

  • Please list EACH doctor that practices at this location.

  • Hygenists at Location

  • Please list EACH dental hygenist that practices at this location.
  • Please enter a number from 0 to 7.
  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 0 to 7.
  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 0 to 7.
  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 0 to 7.
  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 0 to 7.
  • Date Format: MM slash DD slash YYYY

  • Other Office Appointment & Staff Questions

  • IN-OFFICE WAIT TIME (Minutes)
  • Please enter a number greater than or equal to 0.

  • FIRST AVAILABLE APPOINTMENTS (indicate number of calendar days)

  • Office Staff

  • FULL TIME STAFF
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • PART- TIME STAFF
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
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  • When you are satisfied that the answers are both accurate and complete, click the Submit button below. Please only push the submit button once. If you need to revise or confirm the information on the form, please select "Save and Continue Later."
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Contact Us

Phone: (855) 327-9125

NAVIGATION

1. Personal Information
2. Dental Information
3. Licenses
4. DEA
5. General Anesthesia
6. Hospital
7. Undergraduate Education
8. Dental School Education
9. Special Training
10. Board
11. Malpractice
12. Work History
13. Adverse Items
14. Impairments & Limitations
15. Miscellaneous
16. References
17. Aetna Questions
18. Review and Submit Questionnaire