1. Start-Up
2. Established Office
3. Personal Q Only
4. Reminder Email
Personal Questionnaire
Location Questionnaire
New Client Form - Established
Step 1 of 4 - Office Information
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Unique ID
Office Information
Legal Entity name of practice (IRS name registered to the TIN and entity insurance checks are payable to)
Office Manager Name
First
Last
Office Manager Email
Office phone number
Office fax number
Street Address
Suite or Unit
City
State
**State**
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Zip must be a 5 digit number
Time Zone
Eastern
Central
Mountain
Pacific
County
Please don't say USA, this is county not country
Tax ID used for claims
This must match your W9 and your SS4 documents
Type 2 NPI number
This is the office/group NPI #, most solo practices don't have this number. If you plan to participate with BCBS and/or plan on hiring an associate I 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.
Practice Management Software
Dentrix Ascend
Curve
Dentrix
Eaglesoft
Easy Dental
MOGO
Open Dental
PBS Endo
Practice Works
Softdent
TDO
WIN OMS
OTHER
Other Practice Management Software
Give us the name of your practice management software if not listed above
Dentist(s) Personal Information
Please list EACH doctor that practices at this location.
Licensure Name
First
Middle
Last
Owner or Associate?
Owner
Associate
Gender
Female
Male
Type
DDS
DMD
Specialty
**Choose a specialty**
General Dentist
Endodontist
Oral Surgeon
Orthodontist
Pedodontist
Periodontist
Prosthodontist
License Number
Individual NPI #:
This is tied to you as an individual, not the NPI2 (location NPI)
Personal Cell Phone
Personal Email
Is there another dentist at this location?
Yes
No
Doctor #2 Name
First
Middle
Last
Owner or Associate?
Owner
Associate
Gender
Female
Male
Type
DDS
DMD
Specialty
If you are a specialist, you will need to send us a copy of your Specialty Certificate.
** Choose a Specialty **
General Dentist
Periodontist
Pedodontist
Orthodontist
Oral Surgeon
Endodontist
Prosthodontist
Dental License Number
Individual NPI #:
This is tied to you as an individual, not the NPI2 (location NPI)
Cell Phone
Personal Email
Do You Have Another Doctor at This Location?
Yes
No
Doctor #3 Name
First
Middle
Last
Owner or Associate?
Owner
Associate
Gender
Female
Male
Type
DDS
DMD
Specialty
If you are a specialist, you will need to send us a copy of your Specialty Certificate.
** Choose a Specialty **
General Dentist
Periodontist
Pedodontist
Orthodontist
Oral Surgeon
Endodontist
Prosthodontist
Dental License Number
Individual NPI #:
This is tied to you as an individual, not the NPI2 (location NPI)
Cell Phone
Personal Email
Questions asked about your Billing and/or Insurance Participation
When filing claims are you inserting your FULL Fee to the carrier or are you inserting the PPO fee on the claim form?
Full Fee
PPO Fee
If we are adding PPO's please let us know if there are any malpractice claims currently unresolved under any dentist's license numbers
Yes
No
Not Applicable
Additional Information About Malpractice Claim
Please identify the dentist and the date of the malpractice claim.
Have you received any correspondence in the last year from any insurance companies making note of frequencies tied to any codes or have you been through an insurance audit in the last year with any companies?
Yes
No
Insurance Audit Detail
What insurance company did the audit? What codes were in question? What date was the audit (mo/yr)? What were the results of their findings?
Review & Submit
How Did You Hear About Our Services?
*
Consultant
CPA
Dental Town
Facebook
Other Doctor
Class/Conference
Other
Enter Name of Consultant
*
Enter Name of CPA
*
Enter Name of Facebook Group
Enter Name of Doctor
*
Enter Name of Class/Conference
*
If "other" please list:
*
Message to Unlock the PPO
Please only click submit once. If the form was submitted successfully, you'll be redirected to a confirmation page. If you have a problem submitting the document, simply save it and email brenda@unlocktheppo.com and we'll troubleshoot any issues.
