Customer Registration Form with Newsletter Subscription.

DentalBee Billing Registration Form

Registration Form
Client/Account Information
Owner/Dentist name
Office Name
Office Phone
Street address
Street address line 2
City
State
Zip Code
Main Contact person/Title
Main Contact person phone
*Please enter in all email addresses that will be receiving and reviewing reports
Dentist E-mail address *
E-mail address
E-mail address
E-mail address
E-mail address
Dentist Information
Dentist Full Name
SSN#
Tax ID
License#
NPI
Group NPI
How many dentist treating dentist at this location?
*There will be a separate application sent for each additional provider
Questions About Practice
Is your office paperless?

YesNo
Practice management software
What is your practice management client Id number?
Do you have technical support with your dental software??

YesNo
What is their phone number?
Are you Currently sending electronic claims?

YesNo
What service are you using to send claims electronically?
What is that services' phone number?
What attachment software are you using?
Do you use digital radiographs?

YesNo
What is your digital radiography software?
List of IN NETWORK Insurance Companies
Is your office set up with EFT's?

YesNo
If so, please list which insurance companies are enrolled with EFT's
Specific Registration Requests/Details
Should be Empty:

DentalBee Billing Registration Form