Provider Packet Request Form · 2019. 7. 1. · *Important Note: Only requests to join our network...
Transcript of Provider Packet Request Form · 2019. 7. 1. · *Important Note: Only requests to join our network...
-
*Important Note: Only requests to join our network are processed through the email addresses above. If your request does not relate
to a provider joining our network or a packet request, please contact our Provider Services Team at 1-800-822-5353 for further
assistance. V6/2019
Provider Packet Request Form
Please indicate in the email subject line - Packet Request [State] [County].
Dentist First Name: Dentist Last Name: Associate/Owner: NPI: Specialty:
Email Address: Contact Name:
Practice Name: Phone Number:
Address: County:
City: State: ZIP Code:
Mailing Address: (If Different from Practice Address)
City: State: ZIP Code:
Regional Map
Please check the dental network(s) that you wish to join:
PPO (Commercial) Medicare Medicaid DHMO/Direct Compensation
Are the Dentists above being added to an existing participating location? Yes No Is this a new practice location? Yes No
Please complete all fields and email the completed form to the email address* that applies to your state and region: (Refer to the Regional Map below as your guide.)
Central Region: [email protected] Southeast Region: [email protected]
Northeast Region: [email protected] West Region: [email protected]
CheckBox2: OffCheckBox3: OffCheckBox1: OffComboBox2: []ComboBox1: []ComboBox3: []text 3: text 1: text 2: text 4: text 5: text 6: text 7: text 8: text 9: text 10: text 11: text 12: text 13: text 14: text 15: text 16: text 17: text 18: text 19: text 20: text 21: CheckBox5: OffCheckBox7: OffCheckBox6: OffCheckBox8: OffComboBox5: []ComboBox4: []ComboBox6: []CheckBox4: Off