Practice Name:*
Primary Office Contact:*
Primary Practice Address:
Total Revenue:*

Please provide a breakdown by percentage of revenue per carrier:

Metlife:
Delta:
UCCI:
UHC:
BCBS:
Principal:
Medicaid/ Dentaquest:
CIGNA:
Humana:
Guardian:
AETNA:
DHA/Assurant:
Ameritas:
Other:
Fee for Service:
Phone:*
-
E-mail:*
Website
Practice TIN:*
NPI:
Type of Dentist*
If Specialist, state type:
When is the last time you had a carrier fee schedule review?
Are you under contract with a 3rd party rental agreement for any of the carriers you participate in?
When is the last time you updated your UCR? *
If yes, which carriers do you access through this contract?
Additional Comments/Questions: