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Initial Inquiry

"*" indicates required fields


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?*



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

How many dentists are at your address/office in total (including associates and/or specialists even if part time)?*
Do you have ownership in more than one location?*
Are you currently purchasing a practice or did you recently purchase your practice within the last 24 months?*
Have you taken ownership of the practice?*
Was the office a Fee For Service office?*
Is this currently a DELTA only practice?*
Are you currently moving locations, have you moved in the last year or do you plan to move locations in the next year?*
Please answer yes if any of these apply
Do you share office space with any other dentists or practices?*
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.


Current Insurance Contracting

 Current insurance participation with direct contracts for national PPO Carriers - Please answer 'Yes' or 'No' for each company.
Hidden

Aetna*
Ameritas*
Cigna*
Guardian*


Humana*
Principal*
Sunlife*
United Healthcare (UHC)*


Blue Cross Blue Shield (BCBS)*
Non-Negotiable Carrier
Delta*
Non-Negotiable Carrier
Metlife*
Non-Negotiable Carrier
United Concordia (UCCI)*
Non-Negotiable Carrier


Careington PPO*
Not the Discount Plan
Third Party Administrator
Dentemax*
Third Party Administrator
Zelis*
Not the Payent Processor
Third Party Administrator
Connection Dental*
Third Party Administrator

Premier Group*
Third Party Administrator
Additional Carrier not listed above
Additional Carrier not listed above
Additional Carrier not listed above


Are you primarily looking to Add plans or Drop plans?*


Practice Management Software*


Have you contracted with us before?*
(It doesn't have to be exact)
MM slash DD slash YYYY
How did you hear about us?*

Please complete the below with the Owner/Doctor's name and contact information

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




How many dentists are at your address/office in total (including associates and/or specialists even if part time)?*
Additional Doctor's Name:
Do you have ownership in more than one location?*
Is this a practice purchase or acquisition from another dentist in which you are taking over patient charts?*
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?*
Will your startup be part of a DSO?*
Have you signed a lease for your space or closed on your property?*
Have you formed your corporation and confirmed your Tax ID/EIN for your startup practice with the IRS?*
Was a previous dental practice located in your startup space?*
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?*




MM slash DD slash YYYY
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?*
(It doesn't have to be exact)
MM slash DD slash YYYY
How did you hear about us?*

MM slash DD slash YYYY
MM slash DD slash YYYY