• 1. Start-Up
  • 2. Established Office
  • 3. Personal Q Only
  • 4. Reminder Email
  • Personal Questionnaire
  • Location Questionnaire

Qualifying Form - Startup

Step 1 of 5 - Startup Practice Verification

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  • Startup Practice Verification

  • Please note that this form is to verify that you are considered a Start Up practice as far as how we need to classify our work with the insurance companies and how we represent you on their behalf. Please fill out the information below according to your situation:

  • Separately Please Note:
  • Please note that we have certain parameters that we can work with so what one dentist may consider a start up could have restrictions in place we cannot represent if it is actually purchasing charts or 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.
  • Date Format: MM slash DD slash YYYY
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  • Prospective Office Information

  • Date Format: MM slash DD slash YYYY
  • Legal Entity name of practice (IRS name registered to the TIN and entity insurance checks are payable to)
  • An OFFICE PHONE 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 purposes at this time.
  • Zip must be a 5 digit number
  • PLEASE STOP AND WAIT TO MAKE SURE THIS ADDRESS WON'T CHANGE (INCLUDING STE #) BEFORE SUBMITTING THIS FORM
  • The county in the state in which the practice resides. This is not the country.
  • This must match your W9 and your SS4 documents
  • This is a the Office/Group NPI number, most solo practices don't have this number. If you plan on participation with Blue Cross/Blue Shield and/or plan on hiring an associate in 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
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  • Dentist(s) Personal Information

  • This is tied to you as an individual, not the NPI2 (location NPI)
  • This is tied to you as an individual, not the NPI2 (location NPI)
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  • Home Address

  • There are times when carriers must send Fee Schedules directly to the doctor and without having your office opened yet, we would like to give them your HOME address to use:
  • Zip must be a 5 digit number
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  • Review & Submit

  • 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.
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Contact Us

Phone: (855) 327-9125

NAVIGATION

1. Startup Practice Verification
2. Prospective Office Information
3. Dentist(s) Personal Information
4. Home Address
5. Review & Submit