Dentist Support Center

Form Name Online Form PDF Provider Application Forms: Department of Insurance Provider Application Click here Click here Recredentialing Form Click here To complete our online Department of Insurance Provider Application or our Recredentialing Form, you'll need the latest version of Adobe Acrobat. Click here to install. Supplemental Forms Click here Code List Tables Click here W-9 Click here The Choice Plan: Summary Disclosure and Dentist Participation Agreement Click here Evidence of Coverage Click here The Preferred Plan: Summary Disclosure and Dentist Participation Agreement Click here Evidence of Coverage Click here Acceptance, Participation and Professional Review Procedures Click here Claims Submission Guidelines Click here Smile Rider Sign Up Form Click here Click here SecureTrack Dental Click here Authorization Agreement for Direct Deposit Click here Update Office Info Click here Posterior Composite Authorization Form Click here Full Gold Crown Authorization Form Click here

Discount PDF One Yellow Spot Click here EyeMed Vision Discount Plan Click here RX Discount Card Click here

Plan Number:

For Claims Submission: 800.762.3159 937.438.0283 Fax:  937.291.8695 Address: 6683 Centerville Business Pkwy Centerville, Ohio 45459 Network Development Service Click here Dentist Service Click here