Home Page
Contact Us
Your Team
Community Support
Initial Inquiry
"
*
" indicates required fields
Unique ID
A Practice is considered a "Startup" if it has not yet opened it's doors to clientele
Startup Practices must be at least 90 days from opening to qualify for our services
Is this an Established or Startup Practice?
*
Established
Startup
Please complete the below with the Owner/Doctor's name and contact information
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
*
First Name
Last Name
Choose Specialty
*
Choose Specialty
General Practitioner
Endodontist
Oral Surgeon
Orthodontist
Pediatric Dentist
Periodontist
Prosthodontist
Primary Email
*
Secondary Email
Office Phone
*
This is to identify your office if you call in later, we will not call unless requested
Website
*
Practice Location
*
State Where Practice Is Located
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
.
ZIP Code
Office Time Zone
*
Eastern
Central
Mountain
Pacific
How many dentists are at your address/office in total (including associates and/or specialists even if part time)?
*
One
Two or More
Do you have ownership in more than one location?
*
Yes
No
Are you currently purchasing a practice or did you recently purchase your practice within the last 24 months?
*
Yes
No
Have you taken ownership of the practice?
*
Yes
No
What was the closing date?
*
MM slash DD slash YYYY
What is the name of the Previous Owner
*
* If unknown, please type "Unknown"
Was the office a Fee For Service office?
*
Yes
No
Is this currently a DELTA only practice?
*
Yes
No
Is your office currently moving locations?
*
Yes
No
Did your office move locations in the last 12 months?
*
Yes
No
Are all the carriers that you are contracted with showing your new address on your EOBs?
*
Yes
No
Do you have ANY plans to move or change locations in the next 12 months?
*
Yes
No
Do you share office space with any other dentists or practices?
*
Yes
No
Note that if you share an exact address with another dentist who bills under a different tax ID number, those contracts may impact our work, in particular with shared networks. If you continue to request information from us to move forward, please note that our work will be much more restricted. Our services best fit situations where there is one dentist working in the office space.
Do you plan to hire an associate, specialist or partner in the next 12 months?
*
Yes
No
Have you attempted renegotiations by yourself or through another company in the last 36 months?
*
Yes
No
If you negotiated with an insurance carrier(s) is the last 36 months, please tell us which ones and if you received an increase?
Do you plan to add a 2nd location within the next 12 months?
*
Yes
No
Current Insurance Contracting
Current insurance participation with
direct
contracts for national PPO Carriers - Please answer 'Yes' or 'No' for each company.
Hidden
Aetna
*
Yes
No
Ameritas
*
Yes
No
Cigna
*
Yes
No
Guardian
*
Yes
No
Humana
*
Yes
No
Principal
*
Yes
No
Sunlife
*
Yes
No
United Healthcare (UHC)
*
Yes
No
Blue Cross Blue Shield (BCBS)
*
Yes
No
Non-Negotiable Carrier
Delta
*
Yes
No
Non-Negotiable Carrier
Metlife
*
Yes
No
Non-Negotiable Carrier
United Concordia (UCCI)
*
Yes
No
Non-Negotiable Carrier
Careington
*
PPO
Platinum
Discount Only
N/A
Not the Discount Plan
Third Party Administrator
Dentemax
*
Yes
No
Third Party Administrator
Zelis
*
Yes
No
Not the Payent Processor
Third Party Administrator
Connection Dental
*
Yes
No
Third Party Administrator
Premier Group
*
Yes
No
Third Party Administrator
First Dental Health
*
Yes
No
Diversified
*
Yes
No
Other
Additional Carrier not listed above
Other
Additional Carrier not listed above
Other
Additional Carrier not listed above
Is your primary reason for reaching out to us to learn strategy with your contracting or to keep your current contracts but ask for fee increases?
*
Learn Strategy With Contracting
Keep Current Contracts But Attempt Fee Increases
Other
Are there any additional reasons for reaching out?
Practice Management Software
*
Curve
Dentrix
Dentrix Ascend
Eaglesoft
Easy Dental
MOGO
Open Dental
PBS Endo
Practice Works
Softdent
TDO
WIN OMS
DSN
Other
What is your Gross Annual Production?
*
Have you contracted with us before?
*
Yes
No
When did you contract with us previously
*
(It doesn't have to be exact)
MM slash DD slash YYYY
How did you hear about us?
*
DentalTown
Social Media
Consultant Referral
A Previous Unlock the PPO Client
Please provide the name of the referring Consultant/Company
*
Please complete the below with the Owner/Doctor's name and contact information
Name
*
First Name
Last Name
Choose Specialty
*
Choose Specialty
General Practitioner
Endodontist
Oral Surgeon
Orthodontist
Pediatric Dentist
Periodontist
Prosthodontist
Email
*
Secondary Email
Cell Phone
*
This is to identify your number if you call in later, we will not call unless requested
Practice Location
*
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Office Time Zone
*
Eastern
Central
Mountain
Pacific
How many dentists are at your address/office in total (including associates and/or specialists even if part time)?
*
One
Two
Three or More
Additional Doctor's Name:
First Name
Last Name
Additional Doctor's Specialty:
*
Choose Specialty
General Practitioner
Endodontist
Oral Surgeon
Orthodontist
Pediatric Dentist
Periodontist
Prosthodontist
Do you have ownership in more than one location?
*
Yes
No
Is this a practice purchase or acquisition from another dentist in which you are taking over patient charts?
*
Yes
No
All practice purchases are treated as Established Practices. Please restart this form, selecting "Established" as your practice type
Will you be sharing office space with another doctor/practice that currently accepts PPOs?
*
Yes
No
Will your startup be part of a DSO?
*
Yes
No
Have you signed a lease for your space or closed on your property?
*
Yes
No
Have you formed your corporation and confirmed your Tax ID/EIN for your startup practice with the IRS?
*
Yes
No
Was a previous dental practice located in your startup space?
*
Yes
No
If your address is new (new construction, new suite/unit number), have you checked with your local government and the US Postal Service that your address is confirmed and recognized?
*
Yes
No
N/A
Date of Submission
MM slash DD slash YYYY
Days Until Opening
Days_Until_Opening_Disq
When do you plan to open your new office?
*
Please give your best estimation based upon when you would like to see your first patients in your new office.
MM slash DD slash YYYY
Have you contracted with us before?
*
Yes
No
When did you contract with us previously
*
(It doesn't have to be exact)
MM slash DD slash YYYY
How did you hear about us?
*
DentalTown
Social Media
Consultant Referral
A Previous Unlock the PPO Client
Please provide the name of the referring Client/Consultant/Company
*
GP_GP
ORTHO_ORTHO
PEDO_PEDO
ORAL_ORAL
ENDO_ENDO
PERIO_PERIO
PROSTHO_PROSTHO
GP_ORTHO
ORTHO_GP
GP_PEDO
PEDO_GP
ORTH_PEDO
PEDO_ORTHO
ORAL_PERIO
PERIO_ORAL
Specialties_Validation
Specialties_Disq
Premier_States
Disqualified
*1*_Ortho_Practice
*2*_Too_Many_Doctors
*3*_Too_Many_Locations
*4*_Practice_Purchase
*5*_Address_Change
*6*_Group/DSO
*7*_Open_Date
*8*_Specialty_Combinations
*9*_Software
*10*_EOB's
*11*_Adding_Employee
*12*_Second_Location
Date_Today
MM slash DD slash YYYY
Date_Unix
MM slash DD slash YYYY
Date_Value