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DENTIST DIRECT ENROLLMENT FORM Dental & Optical Vision Coverage Dental Administered By: Dentist Direct, LLC. 1010 North 500 East, Suite 101, North Salt Lake, UT 84054 Plan Selection: Choose all that
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How to fill out dentist direct enrollment form
How to fill out dentist direct enrollment form
01
Obtain a dentist direct enrollment form from the appropriate dental insurance provider.
02
Read through the instructions and requirements listed on the form.
03
Provide your personal information, such as your full name, date of birth, and contact details.
04
Fill in your dental practice information, including the name of your clinic, address, and phone number.
05
Indicate your dental license number and any relevant certifications or affiliations.
06
Specify the types of dental services you offer and whether you accept certain insurance plans.
07
Provide your bank account information for direct deposit of payments, if applicable.
08
Review the completed form for accuracy and completeness.
09
Sign and date the form.
10
Submit the filled out dentist direct enrollment form to the dental insurance provider either by mail or electronically, as instructed.
Who needs dentist direct enrollment form?
01
Dentists who wish to enroll as in-network providers with a specific dental insurance provider.
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What is dentist direct enrollment form?
Dentist direct enrollment form is a form for dentists to enroll directly with a dental insurance plan.
Who is required to file dentist direct enrollment form?
Dentists who want to participate in a particular dental insurance plan are required to file dentist direct enrollment form.
How to fill out dentist direct enrollment form?
Dentists can fill out the dentist direct enrollment form by providing their personal information, contact details, professional qualifications, and agreeing to the terms and conditions of the insurance plan.
What is the purpose of dentist direct enrollment form?
The purpose of dentist direct enrollment form is to allow dentists to enroll directly with a dental insurance plan and participate in providing dental services to the plan's members.
What information must be reported on dentist direct enrollment form?
Dentist direct enrollment form may require information such as dentist's name, contact information, license number, specialty, and agreement to abide by the plan's terms.
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