Credentialing Client Discovery Form

(Dental Provider Credentialing)

Purpose:

This form focuses on gathering information on existing billing operations, transition readiness, A/R, denials, reporting, and ongoing revenue-cycle support.

Instructions:

• Complete every applicable field. Select only services currently provided or planned.

• Upload supporting documents through the secure upload fields. Do not email protected or sensitive documents.

• Items marked “if applicable” may not apply to every provider or practice. Upload documentation through the secure portal only.

• Submission does not guarantee payer approval, network participation, or reimbursement.

Application Progress1 / 13
Service: Dental
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Select all states where your organization operates.

Ownership & Control Information

Providers Requiring Enrollment

CPT / CDT / HCPCS Codes Commonly Used

Services Referred Externally

Dental Laboratories Used

Languages Supported

Accessibility Accommodations

Weekday Hours

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Enter the platform used for video visits, phone visits, or teledentistry. Leave blank when None is selected.

Organization Documents

Provider Documents

Upload documents for each provider as applicable.

Draw your signature using your mouse, trackpad, or touchscreen.

Discovery of Services Rendered (Detailed)

Service Category Reference Examples: General Dentistry • Pediatric Dentistry • Orthodontics • Oral Surgery • Endodontics • Periodontics • Prosthodontics • Oral Radiology • Oral Pathology • Dental Anesthesia • Public Health Dentistry • Teledentistry

Thank You!

Your Dental Provider Credentialing Client Discovery Form has been submitted successfully.

Your form is currently in review.

Our Credentialing team will review your information and supporting documentation and contact you if additional information is required.

Organization:
Application Reference:

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