Dental Provider Credentialing

Client Discovery Form

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

Medicare / Medicaid Refused, Terminated, or Excluded?
Payers to Enroll With
Adverse Action Information Disclosure (Please provide Action, Date, and Resolution.)
Additional Notes About Patient Population, Access Needs, Languages, or Community Focus
Specialty Services
Service Delivery Type

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.
Special Instructions

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

Dental Discovery Form Submitted

Thank you for completing the application. We have received your submission and are currently reviewing it. We will contact you shortly with the next steps in your onboarding process. Thank you, and we look forward to working with you.

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