(Short Form) New Doctor- Onboarding [Pleasant Family Dental]

Welcome to Riccobene Associates!

Thank you for accepting our Associate position! Please take 10-15 minutes to complete the initial forms, hyperlinks to ensure we are onboarding and assimilating you to our organization in a timely manner.

There will be other items for you to complete outside of this form (i.e.- Paycom new hire checklist (direct deposit, handbook, tax forms) and doctor biography link to add you to our website. Should you have any questions please contact Nicole Johnson, Nicole.Johnson@brushandfloss.com

Welcome to the Riccobene Associates team!!!! #Changinglivesonesmileatatime
Welcome to Riccobene Associates! Message from Dr. Riccobene!

HUMAN RESOURCES

Contact information: Nicole Johnson, HR Generalist [Nicole.Johnson@brushandfloss.com]
NEW HIRE FORM- W2 employee

Please complete this form to ensure we add you to our HR/payroll system [Paycom]. Once this form is submitted a team member from Human Resources will add you to Paycom. Please check your personal email address (including spam or junk folder) from an email from PAYCOM with your self-service log in username and password. Please follow the following steps:

Download the Paycom app:
Check your personal email address (spam and junk folder) to recieve your self-service username and password
1. Login using the app
2. Setup your new password
3. Setup your security questions
4. Go to 'checklists'
5. Complete the 'new hire checklist'online handbook, tax forms, direct deposit setup, etc.
6. Start exploring the app!
7. In this app, you can enter your hours, submit time off requests, enroll in benefits, view electronic pay stubs, etc.
  Should you have any questions please email HR@brushandfloss.com Welcome aboard!!
State working*
Doctor's Full Name

First NameMiddle NameLast Name
Place of Birth*
City, State, Country (ex: Raleigh, NC, USA)
Date of Birth

MonthDayYear
Date
Social Security Number (XXX-XX-XXXX)
Needed to add you to our payroll system
Are you authorized to work in US or employment eligibility status:*
Hire Date (anticipated start date)

MonthDayYear
Date
Cell Number

Area CodePhone Number
Email address:*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Role:*
Form I9 compliance: copy of driver's license or active passport

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please upload copy for our records Cancelof
copy of social security card

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Form I9 compliance: you can take a picture and upload directly Cancelof
Office location (identified office location if applicable)
Ex: Durham office or Durham and Wakefield or Cary West
Employment status*
If you are a temp doctor please select 'temp'
Educational degree delegation*
example: DDS or DMD
Dental License #*
NPI #*
DEA # (if applicable)*
Put N/A
Several of our payors utilize CAQH for credentialing. Our Credentialing Specialist is requesting access to your ADA profile to initiate the CAQH process on your behalf.
Please provide CAQH # (if applicable)
CV upload

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Current COI malpractice upload*

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Other Comments:

Credentialing

It may take up to 90 days to credential you, so ensuring we have all of the applicable pieces below is vital. Our credentialing team completes all payor applications. Once the applications have been completed by the credentialing team, you will receive an email to sign all necessary documents for processing.
Point of contact: Suzzane Davis, Sonya Myrick, Dawn Gilbertson, credentialing@brushandfloss.com or Suzzane.Davis@brushandfloss.com
Please provide where you went to dental school & graduation month/year:*
Example: UNC Dental School, Graduation July 1995
Have you completed a GPR or AEGD? If yes, please list details
Example: Yes, AEGD completed at ECU Dental School, graduated program in July 2019
Individual NPI#
DEA*
Please enter N/A if you have not applied or have one
Please attach a copy of your DEA below.*

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Dental License #*
Please attach a copy of your Dental License below.*

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YesNoN/A
Upload copy of Specialty certification (if applicable)

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Ex: Pediatric Dentist, Endodontist, etc. [you can use your phone to take a picture] Cancelof
YesNo
If yes, please upload a copy of your board certificate.

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YesNo
If Yes, where do you have Hospital Privileges?
Any pending or previous actions with the Dental Board*
If so, please explain....
Please upload copy of run loss report of your malpractice (if applicable)*

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Any pending or previous malpractice suits?*
If so, please explain....
One of our payors (Principal) is requesting 2 letters of recommendation (can be from anyone). Please upload 2 letters of recommendation here to ensure we are credentialed with this payor:

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One of our Payors is requiring a copy of your driver's license to complete the credentialing process. Please upload a copy of your driver's license here.*

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Please upload copy of CV including work history (you can take picture using your mobile device)*

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Do you have any gaps in work history after graduation?*
If 'Yes', please provide explanations for each gap in your work history*
Please upload copy of individual malpractice insurance (you can take picture using your mobile device)*

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Malpractice: please upload loss history from last 10 years*

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Please complete the link below to complete the: Insurance Credentialing Authorization Attestation & Release Authorization Form.

This will allow for us to expedite the credentialing process to the payors.

https://hipaa.jotform.com/213004261699050

If you have any questions, please reach out to Credentialing@brushandfloss.com.
Are you currently in-network with any payors/insurance companies?*
Example: BCBS, Aetna, Delta Dental, Medicaid

IT (INFORMATION TECHNOLOGY)

Our company currently uses office 365 products. In order to have effective communication you will be receiving a username and password to login to Microsoft Outlook and Microsoft Teams. These 2 products are how we communicate internally to our team members. Please download the: MICROSOFT TEAMS app & setup email instructions below:
Point of Contact: Brian Mullenix, VP of IT Services (Brian.Mullenix@brushandfloss.com)

OPERATIONS

You will be introduced to the office manager (OM) and regional manager (RM) assigned based on your office location virtually. Your OM & RM's responsibility is to ensure you have the tools, equipment and resources to be successful. In addition, they are ultimately responsible in managing the schedule and ensuring we are maximizing it to the best of our capabilities.
Doctor Skills/Capabilities:*
Please complete this based on each procedure
Doctor on-call process: (only applicable per your contract). On call-process is only for our general dentists that rotate twice a year (1 week each). Specialists are secondary on call.
Future Time Off Requests

Please complete this section if you have future time off request needs to ensure that operations can schedule a temp or block the schedule
Please list any future time off requests*
Please note blackout dates: days around Thanksgiving holidays and Christmas Eve, Christmas Day and New Year's Eve will be subject to approval pending rotation of existing doctors. If not needing time off please say 'not applicable'
Procurement

Please note the company is working on a preferred lab vendor list. We will be in touch shortly.
Please complete this section with current labs that you are using today or have used in the past?*

Marketing

Our marketing team is looking forward to meeting and working with you!
Point of contact: Abbie Vogel, Marketing, marketing@brushandfloss.com
Name Badge (confirm how you'd like your name badge)*
Ex: John Doe, DDS or John M. Doe, DDS
Business Cards (confirm how you'd like your name on the business cards)*
please note if you'd like it same as above or different
Name: How would you like your name & title to appear on the website?*
Example: John Doe, DDS, MS
Where are you from? *
Please include where you grew up and went to school?
When and Why did you decide to become a dental professional?*
Please describe your professional background?*
As we market you internally & externally to our patients, are there particular skills or procedures you'd like for us to highlight? Are you sedation certified?*
Your Passion *
What are you passionate about both inside and outside of work?
Personal (What would you like to share about your family life and extracurricular activities?)*
What would you like to share about your family life and extracurricular activities?)
Anything Else?*
Please take sometime to think about any additional information you would like to share with both current and potential patients. This is a great opportunity to let your target audience know why they should choose you as their provider.
Professional Headshot Picture

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Please upload copy of picture for internal communications. Please note, a marketing member may reach out to you for professional photo for website. Cancelof
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HUMAN RESOURCES

Credentialing

IT (INFORMATION TECHNOLOGY)

OPERATIONS

Future Time Off Requests

Procurement

Marketing