Application for Participation
Please complete and sign this form for each participating provider. (Please type or print legibly)
PROGRAMS: DHMO (IL Only) ❑ PPO ❑
X
Name _______________________________________________________________________________________________
Last First Middle
Specialty ❑ GD ❑ Endodontist ❑ Oral Surgeon ❑ Orthodontist ❑ Pediatric Dentist ❑ Periodontist
/ /
Date of Birth _______________Social - -
Security No. _______________________ Center No. (if applicable) ___________
Dental License No. ___________________________________State ________________Exp. Date __________________
Federal Dea No. ___________________________________________________________Exp. Date __________________
State DEA No. ____________________________________________________________Exp. Date __________________
Medicaid No. (if applicable)______________________ NPI I ______________________NPI II ______________________
Gender (please circle) Male Female
PLEASE ATTACH COPIES OF THE FOLLOWING DOCUMENTS TO THIS APPLICATION:
• Copy of license and current state registration(s)
• Copy of current DEA narcotics registration
• Copy of current state controlled substance certificate (if applicable)
• Copy of current malpractice face sheet
• Curriculum vitae/or professional work history document (most current five years)
• A completed W-9 Form for each unique tax identification number
• Copy of specialty certificate or American Board Certification (if applicable)
Completion of this application does not guarantee acceptance into the program.
Return completed application with signed contract to:
Dental Network of America – Attention Network Support
2 TransAm Plaza Drive
Oakbrook Terrace, Illinois 60181
FAX# 630-691-0290
Please retain a copy for your file.
PRACTICE LOCATIONS
PRIMARY OFFICE OFFICE MANAGER
MAILING ADDRESS CITY STATE ZIP COUNTY
OFFICE PHONE NUMBER FAX NUMBER EMAIL ADDRESS FEDERAL TAX ID#
( ) ( )
Regular Office Hours Do you agree to accept new patients
Monday Tuesday Wednesday Thursday Friday Saturday Sunday under the plan?
AM – – – – – – – YES ❑ NO ❑
PM – – – – – – –
Is your office accessible to the physically disabled?
YES ❑ NO ❑
Languages spoken in office______________________________________________________________________________________________________
2ND OFFICE OFFICE MANAGER
MAILING ADDRESS CITY STATE ZIP COUNTY
OFFICE PHONE NUMBER FAX NUMBER EMAIL ADDRESS FEDERAL TAX ID#
( ) ( )
Regular Office Hours Do you agree to accept new patients
Monday Tuesday Wednesday Thursday Friday Saturday Sunday under the plan?
AM – – – – – – – YES ❑ NO ❑
PM – – – – – – –
Is your office accessible to the physically disabled?
YES ❑ NO ❑
Languages spoken in office______________________________________________________________________________________________________
Attach additional pages if necessary.
BILLING INFORMATION
BILLING NAME CONTACT PERSON (if not office mgr.)
MAILING ADDRESS CITY STATE ZIP COUNTY
PHONE NUMBER FAX NUMBER FEDERAL TAX ID # (if different from primary)
( ) ( )
Are other members of your group applying for or If you are applying as a member of a group, list all other
currently participating? members of your group:
YES ❑ NO ❑ Name Specialty
PROFESSIONAL EDUCATION
Dental Education
COMPLETE SCHOOL NAME FROM (month/year) TO (month/year)
MAILING ADDRESS CITY STATE ZIP COUNTY DEGREE RECEIVED
COMPLETE SCHOOL NAME FROM (month/year) TO (month/year)
MAILING ADDRESS CITY STATE ZIP COUNTY DEGREE RECEIVED
Residency
COMPLETE INSTITUTION NAME FROM (month/year) TO (month/year)
MAILING ADDRESS CITY STATE ZIP COUNTY DEGREE RECEIVED
CHAIR OF DEPT./CHIEF OF SERVICE COMPLETED TYPE OF PROGRAM/SPECIALTY
YES ❑ NO ❑
Fellowship(s)/Post Graduate Training (if currently in training, expected date of completion)
COMPLETE INSTITUTION NAME FROM (month/year) TO (month/year)
MAILING ADDRESS CITY STATE ZIP COUNTY DEGREE RECEIVED
CHAIR OF DEPT./CHIEF OF SERVICE COMPLETED TYPE OF PROGRAM/SPECIALTY
YES ❑ NO ❑
Specialty Certification
SPECIALTY CERTIFICATION(S) - (if certified)
DATE OF CERTIFICATION DATE OF RE-CERTIFICATION NAME OF BOARD AND SPECIALTY EXPIRATION DATE (if applicable)
SPECIALTY CERTIFICATION IN PROCESS - ENCLOSE A COPY OF CONFIRMATION LETTER, IF AVAILABLE
NAME OF BOARD EXPECTED DATE OF CERTIFICATION IF WRITTEN/ORAL COMPLETED ON SCHEDULE, GIVE DATES
SPECIALTY EDUCATIONALLY QUALIFIED SPECIALIST DATE OF COMPLETION
YES ❑ NO ❑
WORK HISTORY (Beginning with current practice)
Please provide your professional work history for the past 5 years. Use additional pages if needed.
NAME OF ORGANIZATION OR OFFICE PRACTICE MILITARY (please circle) FROM (month/year) TO (month/year)
YES NO
MAILING ADDRESS CITY STATE ZIP PHONE NO. POSITION
NAME OF ORGANIZATION OR OFFICE PRACTICE MILITARY (please circle) FROM (month/year) TO (month/year)
YES NO
MAILING ADDRESS CITY STATE ZIP PHONE NO. POSITION
NAME OF ORGANIZATION OR OFFICE PRACTICE MILITARY (please circle) FROM (month/year) TO (month/year)
YES NO
MAILING ADDRESS CITY STATE ZIP PHONE NO. POSITION
HOSPITAL AFFILIATIONS (if applicable)
Primary Admitting Facility
COMPLETE INSTITUTION NAME FROM (month/year) TO (month/year)
MAILING ADDRESS CITY STATE ZIP COUNTY SPECIALTY
Secondary Admitting Facility
COMPLETE INSTITUTION NAME FROM (month/year) TO (month/year)
MAILING ADDRESS CITY STATE ZIP COUNTY SPECIALTY
PROFESSIONAL LIABILITY INSURANCE
Please submit a copy of your professional liability coverage ‘face sheet’ showing amounts and dates of coverage.
INSURANCE CARRIER YEARS WITH CARRIER
From: To:
ADDRESS CITY STATE ZIP PHONE NO.
POLICY NO. COVERAGE AMOUNT EXPIRATION DATE
PREVIOUS CARRIER (if less than 5 years with current carrier) YEARS WITH CARRIER
From: To:
ADDRESS CITY STATE ZIP PHONE NO.
POLICY NO. COVERAGE AMOUNT EXPIRATION DATE
PROFESSIONAL LIABILITY EXPERIENCE
Please provide detailed information on the attached Professional Liability Action Explanation Form.
DATE OF OCCURRENCE AMOUNT PAID/IN RESERVE TO RESOLVE CLAIM INSTITUTION INVOLVED (i.e., hospital, etc.)
NAME & ADDRESS OF INSURANCE CARRIER CURRENT STATUS OF CLAIM (open/closed/pending/resolved, etc.)
DETAILS OF ALLEGATIONS:
DATE OF OCCURRENCE AMOUNT PAID/IN RESERVE TO RESOLVE CLAIM INSTITUTION INVOLVED (i.e., hospital, etc.)
NAME & ADDRESS OF INSURANCE CARRIER CURRENT STATUS OF CLAIM (open/closed/pending/resolved, etc.)
DETAILS OF ALLEGATIONS:
DISCLOSURE QUESTIONS
IF YOU ANSWER “YES” TO ANY QUESTION, PLEASE PROVIDE DETAILS ON A SEPARATE PAGE.
INCLUDE A COPY OF ANY ORDER OR SETTLEMENT WHERE APPLICABLE.
1. ■ Yes ■ No Have you ever been disciplined by any State Board of Dental Examiners, or any Professional Conduct
Board? Have you ever been reprimanded or fined by any state or federal agency that disciplines
dentists?
2. ■ Yes ■ No Have you ever had any previous or pending challenges to, or voluntarily or involuntarily relinquished
any professional license(s), narcotics registration, hospital membership or clinical privilege(s) as the
result of any investigation or disciplinary action?
3. ■ Yes ■ No Has your Drug Enforcement Agency or other controlled substances authorization ever been denied,
revoked, suspended, reduced or not renewed? Have proceedings toward any of those ends ever been
instituted?
4. ■ Yes ■ No Has your specialty board certification or eligibility ever been denied, revoked, relinquished, not
renewed, suspended or reduced? Have any proceedings toward any of those ends been instituted?
5. ■ Yes ■ No Have you ever been denied membership, renewal of membership or been subject to any disciplinary
action in any professional society or hospital?
6. ■ Yes ■ No Have your clinical privileges at any hospital or healthcare institution been limited, suspended, revoked,
not renewed or subject to probationary or other disciplinary conditions?
7. ■ Yes ■ No Have you ever been reprimanded, censured, excluded, suspended or disqualified by Medicare,
Medicaid or any other plan for which you provided services?
8. ■ Yes ■ No Have you ever been convicted of a felony or are you presently indicted for a felony?
9. ■ Yes ■ No Do you have or have you had a chemical dependency/substance abuse problem, treated or untreated?
If “yes”, provide details including a copy of the National Practitioner Data Bank report, if reported.
10. ■ Yes ■ No Have there ever been, or are there currently, any claims, settlements or judgements against you, or
have you received any notice of “Intent to File?” If “yes”, please provide detailed information on the
enclosed Professional Liability Action Explanation Form.
11. ■ Yes ■ No Have you ever had any professional liability insurance coverage cancelled, declined or modified (i.e.
reduced limits or restricted coverage)? Has any renewal ever been refused or have you voluntarily
given up coverage?
12. ■ Yes ■ No Do you have a condition which would make you unable, with or without reasonable accommodation to
perform the essential functions of a practitioner in your area of practice without posing a significant
health or safety risk to your patients?
ATTESTATION AND RELEASE
The foregoing information is provided in confidence and is to be used solely for the purpose of credentialing, peer
review and quality assurance processes in accordance with this authorization.
I authorize and release Dental Network of America (DNoA) to request information regarding my professional
credentials and qualifications from educational facilities, professional certification boards, state regulatory and
licensing departments, professional liability insurance carriers, other professional monitoring entities and present and
past employers listed on the foregoing pages. I further authorize those entities to submit any information requested by
DNoA for the purpose of preparing a complete personal portfolio.
I understand and release DNoA to gather, verify and submit this information to those entities with whom I have or wish
to establish contract relationship as a network provider.
I, the undersigned, hereby certify that the information provided in or attached to this application is accurate and
complete. I further understand that the intentional submission of false or misleading information or the withholding of
relevant information is grounds for termination as a participating dentist. I agree to inform DNoA in writing within 30
days if there is any change in the information provided as a result of any developments subsequent to my signing this
application.
_________________________________________________________________
Name (please print or type)
_________________________________________________________________ ___________________________
Signature (original signature required) Date
PLEASE ATTACH COPIES OF THE FOLLOWING DOCUMENTS TO THIS APPLICATION:
• Copy of license and current state registration(s)
• Copy of current DEA narcotics registration
• Copy of current state controlled substance certificate (if applicable)
• Copy of current malpractice face sheet
• Curriculum vitae/or professional work history document (most current five years)
• A completed W-9 Form for each unique tax identification number
• Copy of specialty certificate or American Board Certification (if applicable)
Completion of this application does not guarantee acceptance into the program.
This application can not be processed until it is completed in full.
Return completed application with signed contracts to:
Dental Network of America
Attention Network Support
2 TransAm Plaza Drive
Oakbrook Terrace, Illinois 60181
FAX# 630-691-0290
Please retain a copy for your file.
