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
Firs Name
Last Name
Choose Speciality
Please Select
General Practitioner
Endodontist
Oral Surgeon
Orthodontist
Pediatric Dentist
Periodontist
Prosthodontist
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Time Zone
*
Eastern
Central
Mountain
Pacific
Relation to location
*
Please Select
Current Owner
Current Associate
Prospective buyer of this practice (not officially the owner)
What best describes the Provider Status at your office?
*
I am the current owner, and only provider at this practice
I am one of two doctors at this practice, but the only one contracted or adding participation.
I am one of two doctors at this practice, but we are both interested in reviewing our network participation and contracting, which we believe to be the same.
There are three or more doctors at this practice, but I am the only contracted doctor at this location
Other
Does the dentist who owns this practice also have ownership in another practice currently?*
*
Yes
No
Will you be sharing office space with another doctor/practice that currently accepts PPOs?
*
Yes
No
Do you currently share office space with another practice/dentist who does not use your tax ID?
*
Yes
No
Are you planning to add an associate or specialist to your practice under your TAX ID in the next 12 months?
*
Yes
No
Current Insurance Contracting
Current insurance participation with direct contracts for national PPO Carriers
Aetna
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
Ameritas
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
Cigna
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
Guardian
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
Humana
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
Principal
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
Sunlife
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
United Healthcare (UHC)
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
Blue Cross Blue Shield (BCBS)
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
Blue Cross Blue Shield (BCBS)
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
Metlife
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
United Concordia (UCCI)
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
Delta
*
Direct contract
Through a Shared Relationship
Out of Network
Unsure or No Production
Has your office had an address change?
*
Yes, we have moved and it’s been less than 12 months since in our new location
Yes, we have moved and it’s been more than 12 months in our new location
No, we have not moved yet, but have plans to move within the next 12 months
No, we have not moved and have no plans to
Gross Annual Production (not collections)
*
Less than 500K
$500K - $700K
$700K - 1.3M
$1.3M and above
Additional information you would like us to know about your situation?
Practice Management Software*
Curve
Dentrix
Dentrix Ascend
DSN
Eaglesoft
Easy Dental
MOGO
Open Dental
Oryx
PBS Endo
Practice Works
Softdent
TDO
WIN OMS
Other
Have you previously worked with us in the past?
Yes
No
Submit
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