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DOMINION DENTAL SERVICES, INC. AND DOMINION DENTAL SERVICES USA, INC. PENNSYLVANIA ORTHODONTIC PROVIDER AGREEMENT This Agreement is made and entered into this day of, (year), by and between (hereinafter
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How to fill out pennsylvania orthodontic provider agreement
How to fill out pennsylvania orthodontic provider agreement
01
Obtain a copy of the Pennsylvania Orthodontic Provider Agreement form.
02
Read the form carefully and understand all the terms and conditions.
03
Fill out your personal information, including your name, address, and contact details.
04
Provide your dental practice information, including the name of the practice, address, and contact details.
05
Indicate your dental license number and expiration date.
06
Specify if you are an individual provider or part of a group or organization.
07
Fill in any additional information requested, such as your malpractice insurance details.
08
Review the entire agreement thoroughly to ensure all information is accurate and complete.
09
Sign and date the agreement.
10
Make a copy of the signed agreement for your records.
11
Submit the completed agreement to the appropriate authority or organization as instructed.
Who needs pennsylvania orthodontic provider agreement?
01
Pennsylvania orthodontic provider agreement is needed by orthodontists or dental practitioners who wish to provide orthodontic services in Pennsylvania.
02
It is also required by dental practices or organizations that employ orthodontists or provide orthodontic services in Pennsylvania.
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What is pennsylvania orthodontic provider agreement?
Pennsylvania orthodontic provider agreement is a contractual agreement between an orthodontic provider and a payer in Pennsylvania.
Who is required to file pennsylvania orthodontic provider agreement?
Orthodontic providers in Pennsylvania are required to file the provider agreement.
How to fill out pennsylvania orthodontic provider agreement?
The provider agreement can be filled out by entering the required information and signatures from both parties.
What is the purpose of pennsylvania orthodontic provider agreement?
The purpose of the provider agreement is to outline the terms and conditions of the orthodontic services provided by the provider.
What information must be reported on pennsylvania orthodontic provider agreement?
The provider agreement must include details of the services offered, payment terms, and any other relevant terms and conditions.
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