Inquiry Form – Unlock The PPO

Unique ID

Owner Doctor's First & Last Name*

Owner Doctor's First Name Owner Doctor's Last Name

Email you would like us to send your packet of information to:*

Contact Phone number (won't be used unless you later request we contact you):*

Office Time Zone*

Eastern
Central
Mountain
Pacific

Type of Practice*

Established
Startup

State your practice resides in or will be located in:*

What's is the expected open date of the Startup Practice?*

Zip Code*

Doctor Specialty*

Does/will more than one (1) doctor work at this location?*

Yes
No

If yes, how many doctors work at this location?*

Please enter a number greater than or equal to 2.

Does the owner dentist have ownership in more than 1 location*

Yes
No

Practice Management Software*

Other Practice Management Software*

Gross yearly production (this is only to give you better return on investment feedback):*

Current Insurance Contracting

Check the companies that you have signed direct contracts with currently - YOU MUST ANSWER YES OR NO TO ALL COMPANIES

AMERITAS*

Yes
No

AETNA*

Yes
No

BCBS*

Yes
No

CIGNA*

Yes
No

CAREINGTON*

Yes
No

CONNECTION DENTAL*

Yes
No

DELTA*

Yes
No

DENTEMAX*

Yes
No

FIRST DENTAL HEALTH*

Yes
No

GUARDIAN*

Yes
No

HUMANA*

Yes
No

MAVEREST/ZELIS*

Yes
No

METLIFE*

Yes
No

PRINCIPAL*

Yes
No

SUN LIFE*

Yes
No

UNITED CONCORDIA*

Yes
No

UNITED HEALTHCARE*

Yes
No

Just kidding, my office is kind of a mess and I'm not sure who I have contracts with at all, that's why I'm reaching out to you for help!

Yes

Prospect Form

Step 1 of 2 - Prospect Questions

Current Insurance Contracting