Established Practice Form

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
Email
example@example.com
Phone Number
Please enter a valid phone number.
Practice Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Time Zone*

EasternCentralMountainPacific
Relation to location*
What best describes the Provider Status at your office?*

I am the current owner, and only provider at this practiceI 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 locationOther
Does the dentist who owns this practice also have ownership in another practice currently?**

YesNo
Will you be sharing office space with another doctor/practice that currently accepts PPOs?*

YesNo
Do you currently share office space with another practice/dentist who does not use your tax ID?*

YesNo
Are you planning to add an associate or specialist to your practice under your TAX ID in the next 12 months?*

YesNo
Current Insurance Contracting

Current insurance participation with direct contracts for national PPO Carriers
Aetna*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure or No Production
Ameritas*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure or No Production
Cigna*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure or No Production
Guardian*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure or No Production
Humana*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure or No Production
Principal*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure or No Production
Sunlife*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure or No Production
United Healthcare (UHC)*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure or No Production
Blue Cross Blue Shield (BCBS)*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure or No Production
Blue Cross Blue Shield (BCBS)*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure or No Production
Metlife*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure or No Production
United Concordia (UCCI)*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure or No Production
Delta*

Direct contractThrough a Shared RelationshipOut of NetworkUnsure 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 locationYes, we have moved and it’s been more than 12 months in our new locationNo, we have not moved yet, but have plans to move within the next 12 monthsNo, 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*

CurveDentrixDentrix AscendDSNEaglesoftEasy DentalMOGOOpen DentalOryxPBS EndoPractice WorksSoftdentTDOWIN OMSOther
Have you previously worked with us in the past?

YesNo
Should be Empty:

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

Current Insurance Contracting