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New Client Form (v2)
"
*
" indicates required fields
Step
1
of
2
50%
Unique ID
A Practice is considered a "Startup" if it has not yet opened it's doors to clientele
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
Dentist_Name
*
First
Last
Dentist_Cell
*
Dentist_Email
*
Specialty
*
Choose Specialty
General Practitioner
Endodontist
Oral Surgeon
Orthodontist
Pediatric Dentist
Periodontist
Prosthodontist
Owner or Associate?
*
This refers to this Startup practice only, not any current position held elsewhere
Owner
Associate
Gender
*
Female
Male
Are you still in your residency?
*
Yes
No
Are You Currently Employed at a Dental Practice
*
Yes
No
Will you remain as an associate at another location during the first year of your new practice?
*
Yes
No
Do you need your practice to be flagged so that the carriers do not discuss it with your current employer (if you are working as an associate)?
*
Yes
No
License Number
*
Individual NPI #
*
This is tied to you as an individual, not the NPI2 (location NPI)
Will you have another doctor at your location at opening?
*
Yes
No
Please complete the below with the additional Owner or Associate's name and contact information
Startup_Dentist_Name_2
*
First
Last
Startup_Dentist_2_Phone
*
Startup_Dentist_2_Email
*
Specialty
*
Choose Specialty
General Practitioner
Endodontist
Oral Surgeon
Orthodontist
Pediatric Dentist
Periodontist
Prosthodontist
Owner or Associate?
*
This refers to this Startup practice only, not any current position held elsewhere
Owner
Associate
Gender
*
Female
Male
Gender
*
Female
Male
Gender
*
Female
Male
Gender
*
Female
Male
Are you still in your residency?
*
Yes
No
Are You Currently Employed at a Dental Practice
*
Yes
No
Will you remain as an associate at another location during the first year of your new practice?
*
Yes
No
Do you need your practice to be flagged so that the carriers do not discuss it with your current employer (if you are working as an associate)?
*
Yes
No
License Number
*
Individual NPI #
*
This is tied to you as an individual, not the NPI2 (location NPI)
Office Information
Office_Name
*
Office_Address
*
Street Address
Address Line 2
City
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
Office_County
*
Please enter the County, not Country.
Please ensure that you have entered the
County
and not
Country
Office_Phone
Office_Fax
An Office (Non-Personal) number will be required before getting credentialed with insurance carriers, it is not required at time of contract. We suggest always getting the Land Line as soon as possible even if you haven’t opened. No calls will be directed to this number. Its for Credentialing Only purposes at this time.
Point of Contact (This may be an individual other than the Doctor)
*
Prefix
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Prefix
First
Last
Established_POC_Title
*
Point of Contact Title
Doctor
Office Manager
Front Desk
Insurance Coordinator
Established_POC_Email
*
Tentative Opening Date of Office
*
MM slash DD slash YYYY
Office_TIN
*
This must match your W9 and your SS4 documents (EIN)
Has this TIN/EIN been used for Credentialing before?
*
Yes
No
Have you or anyone else contacted insurance companies on behalf of your new practice/Tax ID/EIN?
*
Yes
No
Practice Management Software
*
Curve
Dentrix
Dentrix Ascend
Eaglesoft
Easy Dental
MOGO
Open Dental
PBS Endo
Practice Works
Softdent
TDO
WIN OMS
DSN
Other
Startup Status
*
This is a complete scratch Startup in an office space that I am currently building/finishing for first time occupancy.
No other business has been located in this space ever.
This is a complete scratch Startup that I am doing in a space that was previously finished/built out by another business.
However, no other dentist has occupied this space in the past.
This is a scratch Startup, but I am taking over space that was previously occupied by another dentist in the past.
This is a scratch Startup, but I am sharing office space with another dentist.
I consider this a scratch Startup, but I am purchasing charts from another dentist
Please note that we have certain parameters that we can work with, so what one dentist may consider a start up may have restrictions in place which change our ability work for you. We cannot represent a Startup practice which is actually purchasing charts, or which may be classified as a practice purchase.
It is also very important to understand that if there was ever any other dentist in the space you will be occupying, those old contracts may affect the ability to utilize shared network agreements for your practice, even if they are years old.
We cannot tell you if any other dentist may have had a contract tied to your location in the past, so this is something very important to research before assuming you will be picked up through shared network agreements.
If we have started work on your contract and have found that the practice has been misrepresented, we reserve the right to terminate the contract without refund of the initial first 1/3 installment of our fee.
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
Other
Please provide the name of the referring Client/Consultant/Company
*
Any Additional Message or Information?
Signature
*
Please only click submit once. If the form was submitted successfully, you'll be redirected to a booking page where you will schedule your Consultation Call. If you have a problem submitting the document, simply save it and email brenda@unlocktheppo.com and we'll troubleshoot any issues.
Questions about your Office
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
When did you start your practice?
*
MM slash DD slash YYYY
Was it a scratch start or purchase?
*
Scratch
Purchase
Previous Owner's Name
*
First
Last
Did that owner participate in PPOs to your knowledge?
*
Yes
No
Unknown
Have you made sure they are no longer listed at your location on the carrier websites?
*
Yes
No
If you have anything unique about yourself or your practice that you would like us to know, please tell us here.
Have you or are you planning to move locations?
*
Yes
No
Have you already moved?
*
Yes
No
Have you notified your current contracts and are seeing the new address reflective on the EOBs?
*
Yes
No
Additional information for us to know regarding your move
Do you have plans to purchase a second location?
*
Yes
No
Approximately how soon would this purchase happen?
*
MM slash DD slash YYYY
If you have anything happening in the next 12 months you think we should know please tell us here
Since you opened, have you had previous associates or specialists working at your location that were contracted with PPOs and listed at your location on carrier websites for patients to see?
*
Yes
No
What were the names of those doctors?
*
Have each of these doctors been terminated off your contracts?
*
Yes
No
Other
Do you have any future plans (within the next 12 months) of adding an associate, specialist, or partner to the practice?
*
Yes
No
Please tell us a little about your situation
*
If you are an office currently accepting PPOs, have you renegotiated your contracts since you initially became credentialed?
*
Yes
No
No, I'm a Fee For Service Office
What year did you last attempt negotiations?
*
Please enter a number from
1990
to
2050
.
Did you use a company similar to ours?
*
Yes
No
What was the name of the company?
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
Other
Please provide the name of the referring Client/Consultant/Company
*
Any Additional Message or Information?
Please only click submit once. If the form was submitted successfully, you'll be redirected to a booking page where you will schedule your Consultation Call. If you have a problem submitting the document, simply save it and email brenda@unlocktheppo.com and we'll troubleshoot any issues.