Provider Checklist

Please use this checklist to ensure that we have the information necessary to process your Dentegra
Participating Provider Agreement. Please be sure to keep a copy of all submitted materials for your
records. Your agreement booklet and necessary attachments should be sent directly to:
Dentegra’s Provider Onboarding
P.O. Box 1850, Alpharetta, GA 30023-1850 or credentialing@dentegra.com

Participating Provider Agreement

Complete, sign and date the agreement
Confidential schedule of contracted fees addendum signed and initial
Indicate your practice DBA name, if applicable
Submit a separate agreement booklet for each separate TIN

Taxpayer Identification Number (TIN) Request Form

Complete, sign and date the form
Provide either your SSN issued by the Social Security Administration or your EIN issued by the
Internal Revenue Service

Confidential Credentialing Information Form — if your state requires a state specific credentialing
form, please submit your state credentialing form in lieu of the included form.
Complete, sign and date the form
Enclose a copy of your current state dental license
Enclose a copy of your specialty certificate or specialty board certification letter, if applicable
Enclose a copy of your current certificate of coverage for your professional liability insurance
Enclose any necessary explanations
Enclose a copy of an assigned Controlled Substance Certificate, if applicable
Enclose a copy of the confirmation letter from the NPPES that indicates the National Provider
Identifier (NPI) you were assigned

Practice Information for Online Dentist Directory

Complete, sign and date the form
Attach a separate Practice Information for Online Dentist Directory for each additional practice

If you have any questions, please contact your local representative at 866-238-1580.

#127949
 INSTRUCTIONS FOR COMPLETION OF THE CONFIDENTIAL CREDENTIAL APPLICATION
The Confidential Credentialing Application must be completed by the Contracting Dentist. Your responses on this application will be
used to determine whether you meet the eligibility criteria for participation in the network. Treating dentists must maintain eligibility
throughout the term of their participation. Responses must be legible. Any response that cannot be completed in the spaces
provided, may be included on supplementary sheets of paper and attached to your submittal. DO NOT LEAVE ANY FIELDS BLANK. If
an item is not applicable, indicate N/A.

YOU MUST INCLUDE THE FOLLOWING WITH THIS COMPLETED APPLICATION

(Use this checklist as a guide)
• Application completed in its entirety for an initial credentialing or recredentialing submittal
• Copy of ALL current State License(s)
• Copy of ALL current DEA Registrations, if applicable
• Copy of current State Controlled Dangerous Substance (CDS) Certificate (if applicable)
• Copy of the certificate of current Professional Liability Insurance policy face sheet, showing expiration dates, dollar amount of
liability limits and Provider’s name.
• Proof of American Board Certification, (in applicable)
• Copy of Curriculum Vitae/Resume (Include last five (5) years of dental work history, or date of graduation from dental school.)
• Copy of Diploma or Specialty training certificate

CONFIDENTIAL CREDENTIALING APPLICATION

Provider Information

Dentist Last Name: _______________________ First Name: ______________________________________________________

Type 1 NPI: __________________ Date of Birth: _______________ (Mandatory fields)

Primary Specialty Type:

 General Dentist  Orthodontist  Oral Surgeon  Prosthodontist
 Pediatric Dentist  Endodontist  Periodontist

Primary Location
Practice Name _______________________________ Start Date (MM/YR) _ ___________________________________________

Practice Address ___________________________________________________________________________________________

City: _ _____________________________________________________________________ State: ______ Zip: __________

Credentialing Contact name: ___________________ Credentialing Contact Email: ______________________________________

Direct Number: _ ___________________________________________________ Fax number: _____________________

Is the practice accepting new patients?  Yes  No

Special services provided at this location (please check all that apply):
 Accessible by public transit  Treats children
 Treats adults with intellectual disabilities  Treats adults with physical disabilities
 Treats children with intellectual disabilities  Treats children with physical disabilities
 Early morning appointments (before 9 am)  Treats special needs children
 Free parking  Evening appointments (after 5 pm)
Provider information cont.
Last Name: _________________________ First Name: ________________________________________ Middle Initial: _ _______
Other name(s) used: _ ______________________________________________________________________________________
Dentist Social Security Number _____________________________ (Mandatory Field Needed For Primary Source Verifications)

 DDS  DMD  OTHER Gender:  Male  Female  Other  Undisclosed

Dental School: _______________________________________________ MM/YYYY Graduated: ___________________________
Specialty School (if applicable): __________________________________ MM/YYYY Graduated: _ _________________________

If you have hospital privileges check here  If no, skip to the next question. If yes, list the hospital(s) for which you have privileges.
__________________________________________

Are you “American Board Certified” in any of the below Specialties (only):
If yes, please check the applicable board
 ABO-Orthodontist  ABOMS-Oral Surgeon  ABP-Prosthodontist
 ABPD-Pediatric Dentist  ABE-Endodontist  ABP-Periodontist

Dental License#: ____________________________________________________ State: ______ Exp. Date ___________________

Additional Dental License(s) #: _ _______________________________________ State: ______ Exp. Date ___________________

DEA Certificate #: ___________________________________________________ DEA Exp. Date: __________________________

If you no longer have a DEA, please complete the below information. If not applicable, please skip to the next question.
Reason for not renewing DEA: ________________________________________________________________________________

If a patient needs narcotics prescribed, they will be:  Referred to another dentist/ oral surgeon  Referred to their primary care
physician. If another dentist is prescribing, please confirm the prescribing dentist’s name below:

Dentist’s name: _____________________________ DEA #: _______________________

Do you have a current license or permit to administer conscious sedation/ general anesthesia?
 Yes  No  N/A
Type:  IV Sedation  General Anesthesia Permit #: ___________________________ Exp. Date: ___________________

Professional Liability Information

Prof. Liability Ins. Co _____________________________________ Policy #: __________________________________________
Liability Limits: (Each Claim)_______________________________ (Aggregate Claim)_ Exp. Date __________________________
Controlled Substance Certificate #: ________________________________ Exp. Date _ _________________________________

Past 5 Years Dental Work History Start Date: MM/ YYYY End Date: MM/ YYYY
1.
2.
3.
4.
5.
Explanation of gaps of six months or more: Start Date: MM/ YYYY End Date: MM/YYYY

If no applicable Dental Work History, please enter your State Board Dental License effective date here: ________________________
 Dentist Name: License number: State Issued:
Professional Attestation and Questions
I. Credentialing History (Please answer questions 1 - 10 below. For any “Yes” answer, explain on a separate sheet of paper.)
Yes No In the Past 10 Years:
  1. Has your license to practice in any jurisdiction, whether past or still pending, been denied, restricted, limited,
suspended, revoked, not renewed, placed under probation, subjected to disciplinary or non-disciplinary action, or
otherwise sanctioned, limited or curtailed?
  2. Has your professional liability insurance ever been denied, suspended, revoked, canceled, or not renewed?
  3. Has your Federal and/or State DEA license or applicable drug license ever been denied, suspended, canceled or
not renewed, or subjected to any disciplinary action?
  4. Has your status as a provider ever been denied, suspended, canceled or sanctioned by any municipal, state,
federal, or any other governmental agency (e.g. Medicare, Medicaid or Denti-Cal) HMO, EPO, PPO or other prepaid
health plan including being listed on OIG, SAMs, or a State Exclusion List?
  5. Are your privileges or memberships at any hospital, institution (Military service) and/or HMO currently under
investigation or have they ever been denied, suspended, reduced or not renewed?
  6. Have you ever been denied membership, or renewal of membership, or been subject to disciplinary proceedings
for a medical, dental or ethical reason by any dental/professional organization?
  7. Are you unable to perform any procedures within the scope of privileges and duties in your position as a health
care provider, with or without reasonable accommodations required by the Americans With Disabilities Act, within
accepted standards of professional performance and without posing a direct threat to patients?
  8. Do you currently, or did you in the last five years, engage in the unlawful use of illegal drugs, including the im-
proper use of prescription drugs?
  9. Do you have any felony or misdemeanor charges pending against you or have you ever been convicted of a felo-
ny, or pleaded “nolo contendere” to a felony?
  10. Have you been involved in ANY malpractice (or any other civil) claims/lawsuits, settlements or judgments within
the last ten years? If yes, please provide detailed information on a separate sheet of paper including: docket num-
ber of the case, location of the court, names of the parties, plaintiff(s) and defendant(s), dates of the incident(s),
description of the incident(s), your involvement, current disposition, and the amount of the settlement(s).

II. Compliance & Malpractice Insurance (Answer questions 11 & 12. For any “NO” answer, explain on a separate sheet of paper.)
Yes No

  11. Do you follow Center for Disease Control Guidelines for Infection Control in Dental Health-Care Settings and
observe all applicable laws and regulations related to the practice of dentistry including, but not limited to, those
dealing with infection control and employee safety in the work place?

  12. Do you have current professional malpractice insurance coverage and agree to maintain continuous, unin-
terrupted coverage while either a contracted dental provider for the Plan or an associate of a contracted dental
provider? Please note that under the terms of participation that you further agree to notify the Plan immediately of
any policy cancellation, lapse in coverage, reduction in coverage maximum(s) or claims made.

I authorize the Plan to consult with professional liability carriers, and other persons or entities to obtain information concerning
my professional qualifications including competence, ethics and other qualifications. I, the undersigned, hereby certify that the
information requested by the Plan and provided herein, is truthful, correct and complete in all respects. I further understand that
the intentional submission of false or misleading information or the withholding of relevant information is grounds for denying
participation or termination as a contracting dentist with the dental plan. The undersigned hereby agrees to notify the Plan
immediately of any changes in the above information.
Upon request, providers have the right to review the information in their credentialing file and to ask for correction of any error
or omission believed to be significant. To be accepted, any such requests must be submitted in writing to the Provider Onboarding
department within 365 days of the provider’s last submission of completed credentialing forms. Providers have the right to submit
a written appeal to refute the basis for any adverse action by the Plan based on credentialing eligibility criteria. The time period
in which to submit a written appeal is subject to state requirements and the provider agreement. If the adverse action decision is
upheld upon appeal, providers may request a hearing before a hearing panel.

Dentist Signature (no signature stamps): Date:

Enterprise Standard Credential Form #129557 (rev. 12/20)

Dentegra Participating Provider Agreement

This agreement (“Agreement”) is entered into by and between the undersigned dentist, dental partnership, professional dental
corporation, dental clinic, or dental care provider (“Provider”) and Dentegra Insurance Company 1 (hereinafter, “Dentegra”).
This Agreement shall become effective upon Dentegra’s initial written notice to Provider as set forth in Section 1.2, below.

RECITALS
A. Dentegra issues or will issue various contracts to purchasers of dental care insurance or dental network access
programs (“Programs”) for designated eligible enrollees (“Enrollees”). Such Programs arrange for certain dental services
(“Program Services”) to be performed by dental care providers contracted with Dentegra (“Participating Providers”).
Program Services include dental care services for which the Program is obligated to pay pursuant to an Enrollee’s
Program contract, or for which the Program would be obligated to pay pursuant to an enrollee’s Program contract but
for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or
lifetime maximums, frequency limitations, or alternative benefit payments.
B. Provider desires to be a Participating Provider in such Programs and therefore agrees to the terms and conditions of
participation as stated in this Agreement.

I. SELECTION AND PARTICIPATION

1.0 Eligibility. To participate in the Programs, Provider must submit all required credentialing documents and information
for each and every licensed dentist (including Provider) whom Provider intends to render dental services to Enrollees on
Provider’s behalf (“Rendering Professionals”) and receive approval from Dentegra for each such Rendering Professional
who meets Program credentialing criteria and periodic recredentialing as determined by Dentegra. Such criteria include,
but are not limited to:
a. Licensure. Each Rendering Professional shall hold and continue to hold a currently valid, unrestricted license to
practice dentistry issued by an appropriate state agency. No Rendering Professional’s license shall have been
suspended, revoked or terminated or subject to terms of probation or other restriction within the past five (5) years.
No Rendering Professional shall have been excluded from participating in any government-sponsored programs.
b. Facilities and Equipment. With respect to each and every facility where Enrollees shall receive treatment, Provider
shall ensure that such facilities are of adequate capacity and are clean, safe and readily accessible to Enrollees. All
equipment used in such facilities shall be licensed and regularly checked as required by state and federal law to
ensure that it meets health and safety standards, is environmentally safe and technically accurate. Personnel
required by law to be licensed or certified to operate such equipment shall be so licensed or certified.
c. Insurance. Provider shall secure and maintain from insurance companies acceptable to Dentegra and approved to
conduct business in the state where Provider is located, professional liability insurance and such other
insurance as required by reasonably sound business judgment to protect Provider and each Rendering Professional
(“Insureds”) and the Insured’s partners, shareholders, directors, officers, members, employees and agents against
losses and liabilities attributable to their acts or omissions in the performance of this Agreement. Such insurance
shall have limits of coverage considered reasonably adequate by Dentegra for the risk insured against. Provider
shall give Dentegra written notice of any policy changes, cancellation or other termination.
1.1 Selection. Dentegra may, at its sole discretion, select Provider for participation, based upon Dentegra’s determination of
Provider’s eligibility. Selection may also be contingent on Dentegra’s need for the Provider’s services, as permitted by
applicable law. Dentegra may also, at its sole discretion, select or deselect individual Rendering Professionals based upon
Dentegra’s quality management program, as described in Section V of this Agreement.
1.2 Notification of Selection. Dentegra shall notify Provider in writing of Provider’s selection as a Participating Provider and
when any Rendering Professional has been approved to treat Enrollees.

1
Or Dentegra Insurance Company of New England, if Provider is located in New York.

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Dentegra Participating Provider Agreement, continued
II. REQUIRED ADMINISTRATIVE PRACTICES, DISCLOSURES AND LEGAL COMPLIANCE
2.0 Dental Services. Provider agrees to provide Program Services for any Dentegra Program to eligible Enrollees in
accordance with the terms, benefits, limitations and/or exclusions for the eligible Enrollee’s Program.
2.1 Availability. Dental services are to be available during Provider’s regular business hours. Emergency Services shall be
available twenty-four (24) hours per day, seven (7) days per week, including vacations and holidays. Provider may not
impose any limitations on the acceptance or treatment of Enrollees not imposed on other patients.
2.2 Locations. Provider shall submit information as required by Dentegra to accurately maintain its records for each office
where Enrollees will receive dental services from Provider. This includes, but is not limited to the name and Tax
Identification Number, as registered with the U.S. Internal Revenue Service to be used by Dentegra to issue payment for
services, any business entity name, new or deleted office locations, the attributes associated with each office (e.g., hours
open, languages spoken), etc. Office locations will not be activated until at least one dentist at the location, in the
appropriate specialty, is approved by Dentegra as a Rendering Professional per Section 1.0.
2.3 Eligibility Verification. Provider shall verify an Enrollee’s eligibility to receive Program Services at or before each visit in
accordance with procedures established by Dentegra. Failure to verify eligibility may result in forfeiture of payment,
including applicable Enrollee payments.
2.4 Enrollee Grievance Procedures. Provider agrees to cooperate with Dentegra in identifying, investigating and resolving
Enrollee grievances pursuant to applicable review procedures as described on our website or in written correspondence
connected with specific grievances, and in accordance with state and federal regulatory guidelines as applicable. Provider
agrees to comply with all final complaint and grievance determinations by Dentegra.
2.5 Standard of Care. This Agreement shall not affect the provider/patient relationship between Provider and Enrollees.
Provider shall render all services in accordance with generally accepted dental practice and standards prevailing in the
professional community at the time of treatment. It is Provider’s responsibility to disclose various treatment options and
the estimated costs associated with each option, regardless of whether or not they are Program Services under the
Enrollee’s Program, and to secure the written consent of the Enrollee per Sections 4.5 and 4.6.
2.6 Rendering Professionals. Each Rendering Professional is required to sign a separate Participating Provider Agreement.
Provider shall not permit any Rendering Professional to provide services to eligible Enrollees on Provider’s behalf unless
such Rendering Professional has been approved by Dentegra as a Participating Provider. Provider shall ensure that each
Rendering Professional complies with the terms and conditions of this Agreement. Rendering Professional understands
and agrees that the Contracted Fees described in Section 4.0 of this Agreement that are established by separate
agreement with Provider/Business Owner, will apply to Provider and all Rendering Professionals contracted under the same
tax identification number (TIN), location and specialty.
2.7 Required Disclosures. Provider agrees to notify Dentegra immediately in writing upon the occurrence or discovery of
any of the following:
a. The license to practice dentistry of Provider or any Rendering Professional expires and/or is not renewed, is
suspended, revoked, terminated or subject to terms of probation or other restriction;
b. Provider or any Rendering Professional becomes the subject of any disciplinary proceeding or action before a state
or federal agency;
c. Provider or any Rendering Professional ceases to participate, is suspended or loses eligibility to participate in any
state or federally sponsored dental program;
d. Provider or any Rendering Professional is accused or convicted of fraud or a felony;
e. The cancellation, termination or expiration of insurance coverage required under this Agreement;
f. A malpractice action is instituted, settled or decided against Provider or any Rendering Professional;
g. Provider files a voluntary petition or an involuntary petition is filed against Provider seeking bankruptcy,
reorganization, arrangement with creditors or other relief under the bankruptcy laws of the United States or any
other laws governing insolvency or debtor relief;
h. An act of nature or any event beyond Provider’s reasonable control occurs which substantially interrupts or
interferes with all or a portion of Provider’s practice or which has a material adverse effect on Provider’s ability to
perform hereunder;
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Dentegra Participating Provider Agreement, continued
i. A material change in the membership, ownership, and/or officers of Provider’s dental practice/corporation; or
j. Any other situation arises which could reasonably be expected to affect Provider’s ability to carry out the obligations
of this Agreement.
To the extent reasonably appropriate and subject to any applicable state or federal fair hearing requirements, Provider
shall immediately restrict, suspend or terminate a Rendering Professional from providing services to Enrollees upon the
occurrence of any of the events referenced in Section 2.7. If Provider fails to act as required by this paragraph with respect
to a Rendering Professional, Dentegra shall have the right to immediately prohibit the Rendering Professional from
continuing to provide services to Enrollees.
2.8 Legal Compliance. Provider and Rendering Professionals shall:
a. Treat Enrollees with the same quality and provide access to care consistent with the balance of Provider’s practice
and not differentiate or discriminate against any Enrollee on the basis of source of payment; and
b. Not unlawfully differentiate or discriminate against an Enrollee, employee or applicant for employment on the basis
of race, religion, color, national origin, ancestry, place of residence, physical handicap, medical condition, marital
status, sexual orientation, age or sex; and
c. Comply with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age
Discrimination Act of 1975, the Americans with Disabilities Act, Public Law 103-227 (US. Pro-Children Act of 1994
[20 USC 6081, et. seq.] and Section 1352 of Title 31), United States Code regarding prohibitions against using
federal funds for lobbying; and
d. Not employ or contract with, directly or indirectly, entities or individuals excluded from participation in Medicare or
Medicaid under sections 1128 or 1128A of the Social Security Act, for the provision of dental services, utilization
review, medical social work or administrative services; and
e. Not condition treatment or otherwise discriminate on the basis of whether an Enrollee has executed an advance
directive (as advance directive is defined under federal law).
f. Comply with all applicable federal, state and local laws and regulations relating to administrative simplification,
security, and privacy of individually identifiable Enrollee information, including but not limited to the federal Health
Insurance Portability and Accountability Act of 1996 (HIPAA).
2.9 Confidentiality of Dentegra Information. Provider and Rendering Professionals shall keep confidential and take
necessary precautions to prevent the unauthorized disclosure of Dentegra’s confidential and proprietary information,
including without limitation its financial arrangements with Participating Providers and any other information compiled or
created by Dentegra and identified in writing as confidential and proprietary. Upon the termination or expiration of this
Agreement, Provider shall return to Dentegra all confidential and proprietary information in the possession of Provider or
any Rendering Professional.

2.10 Provider Directory. Provider authorizes Dentegra and its affiliates to include the name of the Provider and Rendering
Professional(s) and Provider’s office address(es) in lists and directories it provides in various media for the use of current
or prospective Enrollees to whose Programs this Agreement applies. Provider must promptly supply Dentegra with current,
accurate practice information for Provider and all Rendering Professional(s), as necessary for Dentegra to be compliant
with state or federal laws regarding provider directories. Provider must notify Dentegra within five (5) business days when
either closing or opening their practice to new patients.

III. PROGRAM ADMINISTRATION

3.0 Administration. Dentegra shall perform or contract for those services necessary to the administration of the Programs.
3.1 Eligibility/Authorizations. Dentegra shall confirm the Program eligibility of Enrollees and the benefits under the
Enrollee’s Program through the Dentegra website and automated telephone services.
3.2 Processing Policies and Procedures. Dentegra shall make information describing Dentegra’s general policies and
procedures and the policies and procedures of the Programs available to Provider and Rendering Professionals through its
Provider Handbook or website and upon request.
3.3 Benefit Determinations. Dentegra shall be solely responsible for interpreting the terms of and making final benefit
determinations under each Program with respect to Program Services and/or Enrollee payments.

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Dentegra Participating Provider Agreement, continued
3.4 Rationale For Rejection of Claim. Dentegra shall, where required, disclose the rationale used in rejecting or denying a
claim submitted by Provider. Dentegra shall pay Provider’s claims under the Programs in accordance with applicable state
or federal prompt payment laws.

IV. COMPENSATION
4.0 Fees. Dentegra shall establish the fees payable to Provider as set forth in the Confidential Schedule of Contracted Fees
Addendum (or Addenda), applicable to the Rendering Professional’s specialty and region, which is in effect at the time
Program Service is provided to an Enrollee. Dentegra shall pay Provider the portion of such fees that are not payable by
the Enrollee based on the Enrollee’s Program. Such Confidential Schedule of Contracted Fees Addendum (or Addenda) is
incorporated into this Agreement by this reference at the time they are issued to Provider in accordance with Section 8.0
of this Agreement. Any Confidential Schedule of Contracted Fees should not be disclosed by the Provider to a third party
without the express permission of Dentegra. Provider agrees to accept no more than these fees as the total fee chargeable
for Program Services.
4.1 Claim Submission Requirements. For those Programs where Dentegra is responsible for paying any portion of Provider’s
fees, Provider agrees to submit claims and provide Dentegra with claim data according to the policies and procedures set
forth on the Dentegra website and consistent with requests in any written communications between Dentegra and the
Provider. Provider further agrees to follow any applicable state and federal laws with respect to claim submission
requirements or data elements associated with such transactions. This includes, but is not limited to, the guidelines found
in the Health Insurance Portability and Accountability Act (HIPAA). Provider also agrees, upon request, to provide any
other information that will enable Dentegra to meet federal, state and local reporting requirements.
Provider further agrees to:
a. Submit complete and accurate claims for all services provided to eligible Enrollees, whether Program Services or
not;
b. Include the fee regularly charged by Provider for such services;
c. Use claim forms or formats acceptable to Dentegra;
d. Submit claims within twelve (12) months after the date services were performed. Should any amount be denied by
Dentegra for late submission, Provider agrees not to charge the Enrollee any balance that would have been paid by
Dentegra if the claim had been submitted on a timely basis.
4.2 Enrollee Payments. Provider shall bill and collect any deductible, copayment and/or coinsurance from the Enrollee in the
amounts determined by Dentegra to be applicable based on the Enrollee’s Program. Provider shall also bill and collect no
more than the amounts set forth in the Confidential Schedule of Contracted Fees Addendum (or Addenda) for those
Enrollees in network access programs (please refer to paragraph 4.5 for obligations associated with optional treatment
and non-Program dental services). Provider shall not waive, reduce or rebate any amount determined by Dentegra to be
payable by an Enrollee.
4.3 Prohibition Against Certain Billings and Collections. Provider agrees to accept fees described in Paragraph 4.0 plus
the Enrollee payments, pursuant to Paragraph 4.2, as payment in full for Program Services and not to seek any surcharge
or other additional payment, regardless of whether or not payment is received from Dentegra. Whenever Dentegra
receives notice of a surcharge, it shall take appropriate action. Neither Enrollees nor a Program’s sponsoring entity shall
be liable to Provider or any Rendering Professional for any sums owed to Provider by Dentegra. The foregoing shall not
preclude Provider from billing and collecting authorized Enrollee payments pursuant to Paragraph 4.2 or third party
collections in accordance with Paragraph 4.4.
4.4 Third Party Payments. Provider shall cooperate with Dentegra in the proper collection of third party payments including
coordination with other coverage, workers’ compensation, third party liens and other third party liability. Provider agrees
to disclose any other insurance for which the Enrollee is also eligible on any claims submitted to Dentegra. Furthermore,
if Dentegra is secondary, the Provider agrees to provide the explanation of benefits provided by the carrier that adjudicated
the claim as the primary payer.

4.5 Optional Treatment. If Provider proposes to render optional treatment (i.e., a treatment for which the Enrollee’s Program
covers a less expensive professionally accepted treatment), Provider shall obtain an optional treatment form, executed by
the Enrollee or the Enrollee’s legal representative, prior to treatment. Such form shall disclose the Provider’s Contracted
Fee for the optional treatment, the Contracted Fee for the less expensive treatment, and the fact that the Enrollee is

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Dentegra Participating Provider Agreement, continued
responsible for the difference between those fees plus the copayment. Total reimbursement for any optional treatment
shall not exceed the amount listed on the Confidential Schedule of Contracted Fees Addendum (or Addenda).

4.6 Non-Program Services. Provider shall not charge an Enrollee for non-Program Services unless Provider obtains a financial
responsibility form, executed by the Enrollee or the Enrollee’s legal representative, prior to treatment. Such form shall
disclose the Provider’s actual charges for the non-Program Services and the Enrollee’s financial obligation therefor.

4.7 Deductions and Refunds. Dentegra shall have the right to deduct and set off from amounts due to Provider any amounts
owed by Provider to Dentegra or to Enrollees as a result of Provider’s failure to fulfill any business or patient obligation
under this Agreement or Dentegra’s policies and procedures. Enrollees shall not be liable to Provider or any Rendering
Professional for any such amount deducted or set off by Dentegra (or refunded by Provider) and Provider agrees not to
attempt to collect any set off amount from Enrollees or maintain any action at law against Enrollees to collect such
amounts.

4.8 Non-Reimbursable Service Claims Submission. The submission of a claim for items or services which have not been
provided as claimed is not reimbursable under any Program and is subject to applicable provisions of state and federal
criminal laws.

V. QUALITY AND UTILIZATION REVIEW

5.0 Dentegra’s Responsibilities. Dentegra may be required by law to conduct quality and utilization review activities that
identify, evaluate and remedy problems relating to access, continuity and quality of care, utilization and the cost of
services. Dentegra shall maintain standards, policies and procedures for credentialing and recredentialing, and quality and
utilization review of Participating Providers, Rendering Professionals, other health care professionals, and facilities
providing dental services to Enrollees.
As part of its review activities, Dentegra may also use or disclose Provider’s Tax Identification Number (TIN), National
Provider Identifier (NPI) or other attributes to conduct analysis of accessibility, continuity and quality of care or to perform
other dental benefit administration activities.
5.1 Provider’s Responsibilities. Provider and Rendering Professionals shall cooperate and comply with Dentegra, and
designated representatives of organizations engaged by Dentegra, in connection with its quality and utilization review
activities, including but not limited to credentialing and recredentialing, patient record reviews, and facility audits.
5.2 Language Assistance Capabilities. Provider shall contact Dentegra if an Enrollee requests or evidently requires
interpretation services in any language, which services will immediately be arranged by Dentegra at no cost to the Enrollee
or the Provider.

VI. RECORDS AND AVAILABILITY FOR INSPECTION

6.0 Dental Records. Provider shall ensure that an accurate and complete patient (treatment and financial) record for each
Enrollee is established and maintained in Provider’s facility. At a minimum, such records shall include personal and health
information about the Enrollee, a description of all services rendered to the Enrollee, and charges made and payments
received therefore, as dictated by generally accepted dental practice and standards.
6.1 Access to Dental Records. Subject to compliance with applicable federal and state laws and professional standards
regarding the confidentiality of patient records, Provider shall assist Dentegra in achieving continuity of care for Enrollees
through the maximum sharing of patient records for services rendered to Enrollees. Provider’s obligations under this
Paragraph shall include, without limitation:
a. Providing Dentegra with copies of Enrollee patient records that are in the custody of Provider or any Rendering
Professional;
b. Allowing Dentegra authorized personnel, its designated representatives, accreditation and review organizations
and government agencies access to such records on Provider’s premises during regular business hours;
c. Upon reasonable request, providing copies of an Enrollee’s patient records to any other Participating Provider
treating such Enrollee.

6.2 Inspection, Audit and Maintenance. Provider and each Rendering Professional shall maintain the confidentiality of all
Enrollee identifiable information, patient records and treatment in accordance with state and federal law. Provider and
each Rendering Professional shall maintain such records and provide such information to Dentegra, the United States
Nat.Dentegra-ProviderAgreement(08/2016) 5 Version 05/2023
Dentegra Participating Provider Agreement, continued
Department of Health and Human Services, or any other appropriate governmental official having jurisdiction as may be
necessary for compliance by Dentegra with state and federal law and the rules and regulations duly promulgated
thereunder, for a period of at least ten (10) years, or longer as required by state or federal law. All facilities, offices,
records, books and papers of Provider and each Rendering Professional pertaining to Enrollees shall be open to inspection
by Dentegra, its designated representatives, accreditation and review organizations, and state and federal authorities
having jurisdiction over the Program during normal business hours. Provider and each Rendering Professional shall comply
with any requirements or directives issued by Dentegra, accreditation and review organizations and government agencies
as a result of such evaluation, inspection or audit of Provider or a Rendering Professional. The provisions of this paragraph
shall survive termination of this Agreement for the period of time required by state and federal law.

VII. TERM AND TERMINATION

7.0 Term. When executed by both parties, this Agreement shall commence upon the Provider’s selection date as notified by
Dentegra, pursuant to Paragraph 1.2 of this Agreement, and shall continue in effect until terminated in accordance with
the terms of this Agreement.
a. If this Agreement is signed by a Rendering Professional that provides dental services on behalf of and under the TIN
of another Provider, then the term of this Agreement shall coincide with the agreement executed by that Provider,
unless this Agreement is terminated earlier.
7.1 Termination.
a. Provider may terminate this Agreement by giving Dentegra ninety (90) days written notice of termination, subject
to the provisions of Section 8.0 of this Agreement.
b. Dentegra may terminate this Agreement on thirty (30) days written notice, unless a longer notice is required by
law. Dentegra may immediately terminate this Agreement upon the occurrence of any of the events set forth
in Paragraph 2.7 (a) through (e) (Required Disclosures) subject to any applicable limitations of state or federal
law. If this Agreement is terminated by Dentegra, Provider may not seek to become a Participating Provider
until Provider demonstrates to Dentegra’s satisfaction that the issues which resulted in the termination of the
Agreement have been resolved. Furthermore, unless otherwise stated by Dentegra at the time of termination
of the Agreement, Provider may not reapply for participation for a period of at least twelve months following the
termination of this Agreement. Dentegra will provide a terminated Participating Provider an opportunity to appeal
such termination, as required by applicable state or federal law or by Dentegra policies and procedures. Any such
appeal process for termination shall replace the dispute resolution procedures described in Section VIII of this
Agreement.

7.2 Continuing Obligations Upon Termination. In the event of notice of termination of this Agreement or a Program,
Provider shall continue to schedule and honor existing appointments of Enrollees until the effective date of termination.
As of the effective date of termination of this Agreement or a Program, the provisions of this Agreement shall be
considered of no further force or effect whatsoever and each of the parties shall be relieved and discharged here from,
except that:
a. Termination shall not affect any rights or obligations that have previously accrued or shall thereafter arise with
respect to any occurrence prior to the effective date of termination and any such rights and obligations shall continue
to be governed by the terms of this Agreement;
b. Unless Dentegra makes other reasonable and medically appropriate provision for the performance of services,
Provider shall complete all dental services begun (but not completed) prior to termination.
c. Provider agrees to specifically notify all Enrollees that the Provider is no longer contracted to render services as a
Participating Provider.

VIII. MISCELLANEOUS PROVISIONS

8.0 Amendments. Provider agrees to be bound by any amendment to this Agreement or the policies and procedures as
posted on the Dentegra website for contracted Providers, with advance written notice from Dentegra, as required by state
or federal law. If Provider does not wish to be bound by such amendment, Provider shall notify Dentegra of his/her intent
to terminate this Agreement within the notice period. Provider shall comply with any amendment required by law until
the effective date of termination. The foregoing notice requirements shall not apply to amendments agreed to by mutual
written consent of the parties or to amendments required for compliance with applicable law and regulations.
Nat.Dentegra-ProviderAgreement(08/2016) 6 Version 05/2023
Dentegra Participating Provider Agreement, continued
8.1 Governing Law. This Agreement shall be governed, construed and enforced in accordance with the laws of the state
where the Provider is located and the United States of America, as amended, and the regulations adopted thereunder,
including but not limited to those enforced by a state insurance regulatory agency. Any provisions required to be included
in this Agreement by state or federal law or by regulatory agencies with jurisdiction over Dentegra shall bind Dentegra,
Provider and each Rendering Professional whether or not expressly provided in this Agreement. Provider acknowledges
that this Agreement may be subject to approval by such regulatory agencies and may be amended by Dentegra, as set
forth in Paragraph 8.0, in order to comply with applicable law and regulations.
8.2 Incorporation by Reference. All exhibits, addenda and attachments to this Agreement, including Dentegra’s Provider
Handbook, policies and procedures referenced in Section 3.2, are an integral part of this Agreement and are incorporated
in full herein by this reference as if they are set forth at length.
8.3 Entire Agreement. This Agreement, contracted fee schedules, appendices, and amendments hereto, contain all the
terms and conditions agreed upon by the parties regarding the subject matter of this Agreement and supersede all prior
agreements, either oral or in writing, with respect to the subject matter hereof. Notwithstanding the foregoing, this
Agreement is not intended to supersede separate agreements that may be entered into with Dentegra for participation
in other provider networks.
8.4 Independent Contractor Relationship. The relationship between Dentegra and Provider is that of independent
contractors. Provider, Rendering Professionals, and their respective employees and agents are not nor shall they be
construed to be employees or agents of Dentegra. Dentegra, its employees and agents are not nor shall they be construed
to be members, partners, employees or agents of Provider.
8.5 Indemnification. Dentegra and Provider shall each agree to defend, indemnify and hold harmless the other party and its
directors, officers, employees, affiliates and agents against any claim, loss, damage, cost, expense or liability arising out
of or related to the performance or nonperformance by the indemnifying party or their respective employees or agents
under this Agreement.
8.6 Assignment. This Agreement, being intended to secure the personal services of Provider, shall not be subcontracted,
assigned, transferred or pledged in any way by Provider and shall not be subject to execution, attachment or similar
process, except that Dentegra may assign this Agreement and its rights, interests and benefits hereunder to any Dentegra
parent company, affiliate or related entity.
8.7 Disputes. Except as otherwise provided in this Agreement, disputes between Dentegra and Provider arising out of this
Agreement shall be first resolved through the provider dispute process described in the Provider Handbook.
If the provider dispute resolution procedure described above does not resolve the dispute, such dispute shall be subject
to binding arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association
(“AAA”), and judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction. The
initiating party shall give written notice to each other party of its demand to arbitrate on a form provided by the AAA,
which notice shall contain a statement setting forth the nature of the dispute, the amount involved, if any, and the remedy
sought, and shall file at any regional office of the AAA three copies of the notice, together with the appropriate filing fee
required by the AAA. Arbitration hearings shall be held in a regional AAA office unless otherwise agreed upon between
Dentegra and Provider. Such obligations are not terminated upon termination of this Agreement by rescission or
otherwise. Any demand for arbitration shall be submitted within one year from the date of the action that is the subject
of the arbitration.
Provider acknowledges by signing this Agreement that Provider affirmatively agrees to this provision.
8.8 Notices. Any notice required under this Agreement shall be sent to a party’s mailing address of record by United States
first-class mail or by overnight delivery. Any notice sent by U.S. first-class mail shall be deemed to have been received by
the addressee seventy-two (72) hours after the notice has been deposited in the U.S. mail. Any notice sent by overnight
delivery shall be deemed to have been received by the addressee the next business day. Provider also agrees to receive e-
mail communications from Dentegra at the email address shown on the signature page of this Agreement. Either party
may change the place to which notice is being sent by giving written notice to the other of any change of address.

Copyright© 2023 by Dentegra Insurance Company. All rights reserved.

Nat.Dentegra-ProviderAgreement(08/2016) 7 Version 05/2023

Dentegra Participating Provider Agreement, continued

8.9 Signatures: The signatories hereto represent and warrant that they have read the Agreement, understand it and are
authorized to execute it on behalf of their respective principals or co-owners.

IN WITNESS WHEREOF, each of the undersigned has individually executed (in the case of an individual provider) or has
caused this Agreement to be executed by its duly authorized representative (in the case of a dental partnership, professional
dental corporation, dental clinic, etc.) as of the date(s) written below:

(A) an individual dentist owner of his/her practice (unincorporated)

(B) an individual Rendering Professional associated with Provider/business indicated below
(C) a dentist or other authorized person who is an officer of the partnership/corporation/clinic
Title of person signing below ___________________________________________

If the person signing below is a dentist, complete the following:

State License #: Individual NPI (type 1):

Specialty: General Dentist Orthodontist Oral Surgeon Prosthodontist

Pedodontist Endodontist Periodontist

Provider Dentegra Insurance Company or

Dentegra Insurance Company of New England
P.O. Box 1850, Alpharetta, GA 30023-1850
Signature Date

Print Name & Title of Person Signing

Jamie Clarke
Email address for Notices under Section 8.8
Vice President, Network Development

Business Information:

IRS Tax Identification Number (TIN) Business NPI (Type 2)

Legal Name of Dentist/Business Entity County

Business/Mailing Address City State ZIP

Contact Telephone Number Fax Number Email Address

Practice Location Information

Doing Business As (DBA) Name County

Practice Location Address City State ZIP +4 codes

Contact Telephone Number Fax Number Email Address

Please return this entire signed original agreement to Attention: Provider Onboarding. Email to credentialing@dentegra.com. Once the process is
completed, you will receive notice of your participation.

Nat.Dentegra-ProviderAgreement(08/2016) 8 Version 05/2023

Confidential Schedule of Contracted Fees Addendum
This Confidential Schedule of Contracted Fees Addendum (“Addendum”) is an attachment to the Dentegra Participating
Provider Agreement (“Agreement”) between the undersigned individual dentist owner, or other authorized person who is an
officer/dentist of a dental partnership/corporation/clinic (“Provider”) and Dentegra Insurance Company1 (“Dentegra”) related to
Dentegra issued programs ("Programs"). The provisions of this Addendum are to be effective upon Dentegra’s written notice to
Provider and are intended to apply to the contracting Provider and to each Rendering Professional rendering dental services
pursuant to the Agreement.

By completing and signing this Addendum, Provider agrees to the following terms and conditions:
1. Provider has reviewed and agrees to accept no more than the fees which are set forth in the attached Confidential
Schedule of Contracted Fees ("Fee Schedule") for services provided to enrollees covered by Programs. The Fee Schedule is
incorporated herein by this reference.
2. Provider understands and agrees that the amounts listed on the attached Fee Schedule will apply to Provider and all
Rendering Professionals associated to the same tax identification number (TIN), location and specialty indicated below on
this Addendum.
3. This Addendum supersedes and cancels any and all previous agreements between the parties related to compensation for
services provided by Provider for the Programs.

IN WITNESS WHEREOF, the undersigned has individually executed (in the case of an individual provider) or has caused this Agreement
to be executed by its duly authorized representative (in the case of a dental partnership, professional dental corporation, dental clinic,
etc.) as of the date written below:
Provider Dentegra Insurance Company or
______________________________________________ Dentegra Insurance Company of New England
Signature Date P.O. Box 1850, Alpharetta, GA 30023-1850

______________________________________________
Print Name of Person Signing
______________________________________________ Jamie Clarke
Title of Person Signing State License # Vice President, Network Development
(if applicable)

Business Information:
________________________________________________________________________________________
IRS Tax Identification Number (TIN) Legal Business Name Business NPI (Type 2)

________________________________________________________________________________________
Mailing Address City State ZIP

Rendering Professional Information:

Rendering Professional Name Specialty License #

Practice Location Information: (If this Addendum applies to more than one practice location, please use the next page)

________________________________________________________________________________________
Doing Business As (DBA) Name Contact Telephone # Email Address
________________________________________________________________________________________
Physical Address City State ZIP +4 codes

Fee schedule: Initials:

1
Or Dentegra Insurance Company of New England, if Provider is located in New York.

Nat.Dentegra-ScheduleContractedFees(08/2016) Version 05/2023

Confidential Schedule of Contracted Fees Addendum, continued

Additional Practice Locations*

Doing Business As (DBA) name County

Practice Location Address City State ZIP +4 codes

Telephone # Fax # Email Address

Fee Schedule: Initials:

Doing Business As (DBA) name County

Practice Location Address City State ZIP +4 codes

Telephone # Fax # Email Address

Fee Schedule: Initials:

Doing Business As (DBA) name County

Practice Location Address City State ZIP +4 codes

Telephone # Fax # Email Address

Fee Schedule: Initials:

Doing Business As (DBA) name County

Practice Location Address City State ZIP +4 codes

Telephone # Fax # Email Address

Fee Schedule: Initials:

* To help maintain directory accuracy required by state and federal law, a provider can be listed at up to five practice locations.

Nat.Dentegra-ScheduleContractedFees(08/2016) Version 05/2023

 Taxpayer Identification Number (TIN)
Request Form

We require the following information for contracting, claims processing and IRS income reporting purposes.
Please resubmit this form any time you change practices, enter a new partnership or are issued a new Taxpayer
Identification Number.

Please fill out this form completely.

1) Taxpayer Identification Number __________________ 10) Mailing address (if different from practice location):
Address _________________________________________
2) Effective date of TIN _______________________________
City ____________________________________________
3) License number ___________________________________
State ______________ ZIP __________________________
4) Individual NPI (Type 1)______________________________ Phone ( ) ___________________________________
5) Dentist’s name____________________________________ 11) 1099/IRS mailing address:
6) Legal name of the person, partnership or business Same as mailing address, item #10
in which the above TIN (item #1) was issued by
Address __________________________________________
the IRS. If this does not match the IRS’ records exactly,
payments to you may be subject to penalties and City _____________________________________________
backup withholding.*
State ________________ ZIP_________________________
_________________________________________________
12) Type of business entity: Corporation
7) Business NPI (Type 2)_______________________________
Partnership Individual/Sole proprietor
8) Business name (“doing business as”), if different from Other (please specify)___________________________
above. This will be the name that will be printed on
checks (“Payee”). I certify under penalty of perjury that:
_________________________________________________ • The TIN and Payee name I have provided is correct;
• T he Payee is not subject to backup withholding (or
9) Practice location:
see check box below); and
Address __________________________________________ • T he Payee is a U.S. citizen or resident; partnership,
City _____________________________________________ corporation, company or association; or any non-
foreign estate or trust.
State _______________ ZIP (+4 codes)_______________
Phone ( )____________________________________  
Please check here if Payee has been notified by the IRS
that they are currently subject to backup withholding.

Check here to be recognized in Dentegra claims processing system as a nonparticipating provider.

Signature _______________________________________________ Date ____________________________________________

Please return this form to your local Dentegra:

Dentegra Insurance Company
ATTN: Provider Onboarding
P.O. Box 1850
Alpharetta, GA 30023-1850
Email: credentialing@dentegra.com
(continued on next page)
Purpose of TIN Request Form Penalties
We are required to file an information return with the IRS Failure to Furnish TIN. If you fail to furnish your correct
and must obtain your correct TIN to report income paid TIN, you are subject to a penalty of $250 for each such
to you. Furnishing your correct taxpayer information and failure unless your failure is due to reasonable cause and not
making the appropriate certifications will prevent certain to willful neglect.
payments from being subject to backup withholding.*
Civil Penalty for False Information with Respect to
We use this form as a substitute for the IRS Form Withholding. If you make a false statement with no
W-9 (Request for Taxpayer Identification Number and reasonable basis that results in no backup withholding, you
Certification). Please refer to Form W-9 and its instructions if are subject to a $500 criminal penalty.
you require additional information.
Criminal Penalty for Falsifying Information. Willfully
falsifying certifications or affirmations may subject you to
*What is Backup Withholding? criminal penalties including fines and/or imprisonment.
Businesses making certain payments to you are required to Misuse of TINs. If the requester discloses or uses TINs in
withhold and pay to the IRS 28% of such payments under violation of Federal law, the requester may be subject to civil
certain conditions. This is called “backup withholding.” If and criminal penalties.
you provide the correct TIN and name combination and
make the appropriate certifications, your payments will not
be subject to backup withholding. Payments you receive will Privacy Act Notice
be subject to backup withholding if: (1) You do not furnish Section 6109 of the Internal Revenue Code requires you
your TIN to the requester, (2) The IRS notifies the requester to furnish your correct TIN to businesses that must file
that you furnished an incorrect TIN or name, or (3) You do information returns with the IRS to report income paid to
not certify your TIN. you. The IRS uses the numbers for identification purposes
and to help verify the accuracy of your tax return. The
See IRS Form W-9 regarding exemptions from backup
IRS may also provide this information to governmental
withholding.
agencies to carry out tax laws. The IRS may also disclose this
information to combat terrorism.
Specific Instructions for Individuals and Sole
You must provide your TIN whether or not you are required
Proprietors
to file a tax return. Payers must generally withhold 28% of
Individual payees must generally provide their SSN as their taxable payments to a payee who does not furnish a TIN to
TIN and the name shown on their social security card on a payer. Certain penalties may also apply.
line 6. If you have changed your last name, for instance,
due to marriage, without informing the Social Security
Administration of the name change, please enter the name
shown on your social security card on line 5 and your new
name on line 6.
Sole proprietors must furnish their individual name and SSN,
which is preferred by the IRS, or employer identification
number (EIN) as their TIN. Enter your name(s) as shown on
your social security card and/or as it was used to apply for
your EIN on Form SS-4. You may also enter your business
name or “doing business as” name on line 7.

Copyright © 2020 Dentegra. All rights reserved.

TIN #128601 (04/20)
 Practice Location Information For Online Provider Directory
Instructions
A. If you are responding to a directory information request from us, please enter the Case Number
indicated on the letter: _________________.
B. If you are new to Dentegra, please enter all the information requested on this form.
C. If you are currently a contracted network provider:
• Log in to (or register for) your online account. Go to My Account to review and edit your directory
profile and/or attest that your directory profile is correct.
• Or, use this form to enter just the information that needs to be updated in your directory profile and/
or to attest that your directory profile is correct. (Use “Find a Dentist” at dentegra.com to access and
review your current directory profile.)

D. Practice location name (doing business as): ________________________________________________

Practice location address: _______________________________________________________________
City: _________________________ County: _______________ State: _________ ZIP: _____________
Practice location telephone: ___________________________ Practice location fax: _______________
Taxpayer Identification Number (TIN): ________________ Organization NPI (Type 2): ______________
Practice location NPI and type: ______________________
E. Provider name: _________________________________________________________________________
First name Initial Last name

Specialty: __________________________________ License number: __________________________

Provider's NPI (Type 1): ________________________ ¨ Male ¨ Female

F. Dental school #1: _________________________________________ Graduation year: _____________

Dental school #2: _________________________________________ Graduation year: _____________

G. Type of practice:
¨ Solo ¨ Clinic ¨ Dental school ¨ Mobile clinic ¨ Tribal clinic ¨ ECP ¨ FQHC
¨ Group practice ¨ Community clinic ¨ Other ________________________________________

5. Practice location Internet access: ¨ Yes ¨ No

Practice location website address: _________________________________________________________
Practice location email: __________________________ Directory email: __________________________
6. Special services provided at this location (please check all that apply):
¨ Accessible by public transit ¨ Treats special needs adults ¨ Treats children
¨ Early morning appointments (before 9 am) ¨ Treats special needs children ¨ Free parking
¨ Evening appointments (after 5 pm) ¨ WiFi in waiting room
7. Office hours:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

16 (Continued)
8. Wheelchair accessibility:
Your office can be listed as accessible to persons who use wheelchairs if it meets certain “functional
accessibility guidelines.” Please indicate whether your office meets each of these guidelines:
A. Doorways and entrances to the building and office are at least 32" wide. ¨ Yes ¨ No
B. Hallways are at least 36" wide, with sufficient room for a wheelchair to make
necessary turns. ¨ Yes ¨ No
C. There is enough room for a wheelchair user to travel from the waiting area to
the treatment area. ¨ Yes ¨ No
D. The restroom has an accessible doorway, at least 48" of clear floor space,
and grab bars to allow transfer to/from a wheelchair. ¨ Yes ¨ No
E. The building or office is accessible by more than stairs or a steep slope. ¨ Yes ¨ No
F. If the building has parking facilities, there are parking spaces reserved
for people with disabilities. ¨ Yes ¨ No
9. Languages spoken other than English by medical interpreter office staff:
Provider ¨ Staff Language(s) spoken: ___________________________________________________
Provider ¨ Staff Language(s) spoken: ___________________________________________________

Compliance with state and federal regulations requires Dentegra to periodically verify the accuracy of
provider information in our directories. Please provide your contact information in case we need to clarify
any statements or data before updating our online provider directory.
Practice location name: __________________________ Address: ____________________________________
City: __________________________________________ State: ______________ ZIP: ____________________

Contact person's name: Practice manager:

Telephone number: ( ) Telephone number: ( )

Email: Email:

¨ I am new to Dentegra. My practice information is indicated on this form.

¨ I am currently contracted with Dentegra. Update my directory listing as indicated on this form.
¨ I attest that my practice information is accurate in Dentegra's online directory. No changes are
necessary.
¨ I attest that the provider(s) listed below no longer treat patients nor submit claims from this location as of
the date indicated.
(Dentegra will inactivate the network status at ths location for providers listed below. If necessary, use an
additional sheet of paper to list more providers. Please don't use this form to add new providers.)

Providers no longer at this location (first and last names) License number Date

By signing below, I attest that the information entered on this form is correct.
____________________________________ _________________________________ ___________________
Print name and title Signature Date

Please return this form:

Attn: Provider File Maintenance
P.O. Box 1850
Alpharetta, GA 30023-1850

Copyright © 2016 Dentegra. All rights reserved.

17 #99700 (rev. 8/16)
Electronic Funds Transfer (EFT) Authorization Agreement
Please complete a separate form for each TIN. (*) indicates required fields within each section. Please make sure you don’t
miss anything, and that your signature is clear and legible to avoid any processing delays.

Things to know before you begin: Information we need:

• Your enrollment request may take up to 3 weeks to process. • Provider Information
• If after 3 weeks you do not start receiving EFT payments, please let us know. • Financial Institution
• For more information, please see page 3, or online at dentegra.com.

Provider Information
*Provider Name
Last First Middle Initial

Doing Business As (DBA)

*Provider Address
Street

*City *State/Province *ZIP Code

Provider Identifiers Information
*Provider Federal Tax Identification Number (TIN)
or Employer Identification Number (EIN)

*National Provider Identifier (NPI)

Provider Contact Information

*Provider Contact Name Title

*Telephone Number

*Email Address Fax Number

Financial Institution Information

*Financial Institution Name

Example:
*Financial institution routing number

Provider’s account number with financial institution

Type of account at financial institution Checking Savings
Account Number Linkage to Provider Identifier
Provider Tax Identification Number (TIN) National Provider Identifier (NPI)
Please send a copy of a voided check or a letter from your bank with your paper enrollment form so that we can begin the
enrollment process right away.
Submission Information
Reason for submission: New Enrollment Change Enrollment Cancel Enrollment
Authorized Signature

Written Signature of Person Submitting Enrollment

Printed Name/Title of Person Submitting Enrollment

Submission Date / /

Page 1 of 3
Electronic Funds Transfer (EFT) Agreement
You represent and warrant that you are authorized to enroll/update direct deposit information on behalf of respective
principals or co-owners. By confirming your preference for EFT, you authorize Dentegra Insurance Company and its affiliates to
initiate credit entries to the institution and financial account specified.

When your office registers to participate in EFT, you will start receiving claim statements electronically. We will no longer mail
paper copies of claim statements to the registered office’s address. You will receive an alert at the email address on file and
claim statements may be accessed through your Provider Tools account on dentegra.com.

Please return this form to us at:

Dentegra Insurance Company
P.O. Box 1850
Alpharetta, GA 30023-1850
Email: customerservice@dentegra.com

Page 2 of 3
Instructions for Completing the EFT Enrollment Form
Please complete all fields. Keep in mind that your enrollment request may take up to 3 weeks to process. If after 3 weeks you
don’t start receiving EFT payments, please let us know.

If you have any questions about your EFT payments, please let us know. To help us locate your enrollment request, please
have the Trace Number and ACH Payment Related Information handy. If this information isn’t available on your EFT or banking
statements, your bank or financial institution can provide it.

Provider Name. Complete legal name of institution, corporate entity, practice or individual provider

Doing Business As Name (DBA). A legal term used in the United States meaning that the trade name, or fictitious business
name, under which the business or operation is conducted and presented to the world is not the legal name of the legal
person (or persons) who actually own it

Provider Address:
• Street. The number and street name where a person or organization can be found
• City. City associated with provider address field
• State. ISO 3166-2 Two Character Code associated with the State/Province/Region of the applicable Country
• ZIP Code/Postal Code. System of postal-zone codes (ZIP stands for “zone improvement plan”) introduced in the U.S. in
1963 to improve mail delivery and exploit electronic reading and sorting capabilities

Provider Identifiers:
• Provider Federal Tax ID Number (TIN) or Employer ID Number (EIN). A Federal Tax Identification Number, also known
as an Employer Identification Number (EIN), is used to identify a business entity
• National Provider Identifier (NPI). A Health Insurance Portability and Accountability Act (HIPAA) Administrative
Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare
providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial
transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This
means that the numbers do not carry other information about healthcare providers, such as the state in which they live or
their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions

Provider Contact Information:

• Provider Contact Name. Name of a contact in provider office for handling EFT issues
• Telephone Number. Associated with contact person
• Email Address. An electronic mail address at which the health plan might contact the provider

Financial Institution Information:

• Financial Institution Name. Official name of the provider’s financial institution
• Routing Number. A 9-digit identifier of the financial institution where the provider maintains an account to which
payments are to be deposited
• Type of Account. The type of account the provider will use to receive EFT payments e.g., Checking, Saving
• Account Number. Provider’s account number at the financial institution to which EFT payments are to be deposited
• Account Number Linkage to Provider Identifier. Provider preference for grouping (bulking) claim payments – must
match preference for v5010 X12 835 remittance advice

We’re here to help

Please call us if you have questions. You can reach us at 877-280-4204, Monday through Friday, 7 am to 8 pm Pacific.

DG-FM02 #136295B (rev. 03/23)

Page 3 of 3