Provider Contact Information
Tell us about the Dentist
Full Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Is this a What'sApp Number?
*
Please Select
Yes
No
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Point of Contact
Tell us about the person who will be the day to day contact, conduct training, and oversight to your Virtual Assistant
Full Name
*
Title
*
Please Select
Dentist (self)
Manager
Front Receptionist
Treatment Coordinator
Other
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
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Practice Information
Information necessary for coordinating insurance eligibility, verification, etc.
Practice Name
*
Provider NPI
*
Email Credentials
*
Email provider and login information
Phone System Credentials
*
Phone system provider and login information
Fax Number & Credentials
*
Fax provider and login information
Practice Management System
*
Ex: Dentrix, Eaglesoft, OpenDental, etc and login information
Practice Insurance Status
*
List of carriers accepted by practice and in-or-out of network statuses
Practice Hours
*
Provide the office hours of your practice
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Tasks for your Virtual Assistant
*
Insurance Verifications
Insurance Claims
Answering Inbound Calls
Conducting Outbound Calls
Other
Virtual Assistant Expectations
Information for us to source a candidate to meet your expectations
Virtual Assistant Work Schedule
Mon: Tues: Wed: Thurs: Fri:
Clarify the hours you want your virtual assistants to work. You can change this at anytime.
Anticipated Start Date
*
-
Month
-
Day
Year
Select your ideal date for us to start
Additional Comments
Did we miss anything? Include it here!
Attachments
Browse Files
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Choose a file
Please include any attachments (e.g., scripting, insurance lists, appointment policies, etc.) that would help us better.
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