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All information below must be for the Doctor requesting services. If you are an individual who is completing this form on behalf of a Doctor, please do not enter your own name or information


Name*
This is to identify your office if you call in later, we will not call unless requested
Practice Location*
Office Time Zone*

Name of Selling Dentist*

Is your office accepting or considered in network with more than 2 PPOs/insurance carriers?*
What best describes the Provider Status at your office?*
Dentist who will remain out of network*
Second Dentist*
Our package does not apply for dual specialty offices - Do you confirm both doctors will work under the same specialty?*
Does the dentist who owns this practice also have ownership in another practice currently?*
Will the dentist be adding a second location or satellite office in the next 12 months?*
Do you currently share office space with another practice/dentist who does not use your tax ID?*
How does the Post Office differentiate between the two practices?*
Are any of the listed Providers contracted with PPOs?*
Are you planning to add an associate or specialist to your practice under your TAX ID in the next 12 months?*
Are you wanting this provider included in our package?*
What stage of this process would you consider yourself in?*
Are you wanting them included as a contracted provider?*
Name of New Hire*


Current Insurance Contracting

 Current insurance participation with direct contracts for national PPO Carriers
Aetna*
Ameritas*
Cigna*
Guardian*
Humana*
Principal*
Sunlife*
United Healthcare (UHC)*
Blue Cross Blue Shield (BCBS)*
Metlife*
United Concordia (UCCI)*
Delta*
Dentemax*
Third Party Administrator
Zelis*
Not the Payment Processor
Third Party Administrator
Connection Dental*
Third Party Administrator
Careington Care PPO*
Third Party Administrator
Careington Platinum PPO*
Third Party Administrator
If you are with Careington Care PPO, please check the top right corner of your fee schedule and list your CI number
If you are with Careington Platinum PPO, please check the top right corner of your fee schedule and list your CP number

Premier Group*
Third Party Administrator
First Dental Health*
Third Party Administrator
Diversified*
Third Party Administrator
Additional Carrier not listed above
Additional Carrier not listed above
Additional Carrier not listed above


Within the last 3 years, have you added a new contract or negotiated directly with a carrier, where you received an increase in fees?*
Has your office had an address change?*
Previous Address*
Are your EOBs & carrier online listings reflecting the new address?*
Gross Annual Production (not collections)*

How does your office perceive itself, and what is the reason for your interest in our services?*
Can pick up to 2 options
Feedback about your office and the reason for your interest in our services? (CHOOSE BEST OPTION)*

Practice Management Software*

Have you previously worked with us in the past?*
Was this a Startup or Established office?*
Was our last package with you at this same address?*
Any changes with contracted providers?*

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