Get the free MODIFICATION TO DENTAL PROVIDER INFORMATION FORM

This form is used by dental providers to notify Express Scripts Canada of any changes to their provider information, including communications, contact information, and banking details.

How to fill out modification to dental provider

How to fill out MODIFICATION TO DENTAL PROVIDER INFORMATION FORM

1. Obtain the MODIFICATION TO DENTAL PROVIDER INFORMATION FORM from your dental office or insurance provider.
2. Read the instructions carefully to ensure you understand the sections that need to be filled out.
3. Fill in your basic information, such as your name, contact details, and provider ID where applicable.
4. Provide any necessary updates regarding your dental provider's information, such as changes in address, phone number, or practice details.
5. Include relevant dates to indicate when the changes took effect.
6. Review the completed form for accuracy and ensure all required fields are filled out.
7. Sign and date the form at the designated area.
8. Submit the form through the recommended method, such as mailing or emailing it to the appropriate department.

Who needs MODIFICATION TO DENTAL PROVIDER INFORMATION FORM?

1. Dental providers who have recently changed their practice information, such as address, phone number, or any other contact details need this form.
2. Insurance companies that require updated information from their network providers.
3. Patients who need their dental provider's information revised in their health plan records.

For pdfFiller’s FAQs

What is MODIFICATION TO DENTAL PROVIDER INFORMATION FORM?

The MODIFICATION TO DENTAL PROVIDER INFORMATION FORM is a document used to update or change details related to dental providers, including changes in practice location, ownership, or any relevant information that needs to be communicated to regulatory bodies.

Who is required to file MODIFICATION TO DENTAL PROVIDER INFORMATION FORM?

Dental providers who need to update their information with insurance companies, regulatory agencies, or other relevant entities are required to file the MODIFICATION TO DENTAL PROVIDER INFORMATION FORM.

How to fill out MODIFICATION TO DENTAL PROVIDER INFORMATION FORM?

To fill out the MODIFICATION TO DENTAL PROVIDER INFORMATION FORM, follow the instructions provided on the form, including entering the current provider information, specifying the types of modifications needed, and supplying any supporting documentation as required.

What is the purpose of MODIFICATION TO DENTAL PROVIDER INFORMATION FORM?

The purpose of the MODIFICATION TO DENTAL PROVIDER INFORMATION FORM is to ensure that accurate and up-to-date information is maintained in the records of dental providers, which is essential for billing, insurance claims, and regulatory compliance.

What information must be reported on MODIFICATION TO DENTAL PROVIDER INFORMATION FORM?

The information that must be reported on the MODIFICATION TO DENTAL PROVIDER INFORMATION FORM typically includes the provider’s name, practice address, license number, nature of the modifications, and any other pertinent details that may affect their practice or credentialing.