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1 PARTICIPATING PROVIDER APPLICATION Please complete the following information and mail to: Dental Direct 2 South Road, Suite 44-2, Poughkeepsie, NY (888) The following items must be included for application approval; DEA License, Dental License, Medical Malpractice Insurance PRACTICE INFORMATION (*Information included in Directory Webpage Practice Profile) *Dental Office *Street Address: *City: State: Zip: *Telephone: * address: *Website URL: Tax ID # (required): *Fax: National Provider ID (Corporate/Group, if applicable): Office Manager/Contact OFFICE PROFILE DETAILS (The below information is included in Directory Webpage Practice Profile to increase search visibility.) Hours of Operation: q Monday Specialties: q Endodontics Services: q Cosmetic Dentistry Language: q English q Tuesday q Oral Surgery q Dental Implants q Spanish q Wednesday q Orthodontics q General Dentistry q French q Thursday q Periodontics q Restorative Dentistry q Other q Friday q Pedodontics q Teeth Whitening q Saturday q Prosthodontics q Veneer/Laminate q Sunday q In-Office Crowns Healthcare Preferences Available: q Evening Hours q Weekend Appointments q Specialists On Site q Advanced Technology q Sedation Available q 3D Imaging q ConeScan q Paperless Environment Insurance Participation:
2 if there are additional providers, then attach supplemental copies of information PROVIDER INFORMATION (List each dentist you want to add on panel as a participating Dental Direct provider.) First Last Additional Providers First Last First Last COPIES TO ATTACH FOR PARTICIPATING PANEL PROVIDER (*required) qdea License* qdental License* qmedical Malpractice Insurance* Please complete the following information and mail to: Dental Direct 2 South Road, Suite 44-2 Poughkeepsie, NY Fax Application to: (800) 556-1
3 General Dentist Schedule Dentists may add additional lab fees to discounted services with* DIAGNOSTIC & PREVENTATIVE D01 Periodic Oral Evaluation D0140 Limited Oral Evaluation - Problem Focus D0 Comprehensive Oral Evaluation D0210 Xrays Complete Series D02 Xrays Periapical 1st Film D02 Xrays Periapical Each Additional D0274 Bitewings Four Films D03 Panoramic Film D04 Diagnostic Casts D1110 *Prophylaxis Adult Cleaning D11 *Prophylaxis Child Cleaning D13 Fluoride D13 Oral Hygiene Instructions D1351 Sealant Per Tooth No Age Limit RESTORATIVE D2140 Amalgam One Surface D2 Amalgam Two Surfaces D2160 Amalgam Three Surfaces D2161 Amalgam Four Surfaces D23 Resin Based Composite One Surface - Anterior D2331 Resin Based Composite Two Surfaces - Anterior D2332 Resin Based Composite Three Surfaces - Anterior D2391 Resin Based Composite One Surface - Posterior D2392 Resin Based Composite Two Surfaces - Posterior D2393 Resin Based Composite Three Surfaces - Posterior D2394 Resin Based Composite Four Surfaces - Posterior D2 * Crown Porcelain Fused to High Noble Metal D22 * Crown Porcelain Fused to Noble Metal D29 Recement Crown / Bridge D29 Core Buildup Including any Pins D2951 Pin Retention - Per Tooth in Addition to Restoration D2954 Prefabricated Post & Core D29 Provisional Crown *D1110, *D11 (exam & x-ray can be charged in addition) ENDODONTICS D3110 Pulpotomy (Excluding Final Restoration) D31 Pulp Cap Indirect D32 Therapeutic Pulpotomy (Excluding Final Restoration) D3310 Root Canal Anterior D33 Root Canal Bicuspid D33 Root Canal Molar No Charge PERIODONTICS D4210 Gingivectomy Per Quad D4211 Gingivectomy Per Tooth D4341 Perio Scaling/Per Quadrant D4381 Localized Delivery of Antimicrobial Agents Via a Controlled Release Vehicle into Diseased Crevicular Tissue - Per Tooth, By Report D4910 Perio Maintenance PROSTHODONTICS - REMOVABLE D5110 *Complete Denture Maxillary D51 *Complete Denture Mandibular D51 *Immediate Denture Maxillary D5140 *Immediate Denture Mandibular D5213 *Maxillary Partial - Denture Bases (Including any Conventional Clasps, Rests or Teeth) D5214 *Mandibular Partial - Denture Bases (Including any Conventional Clasps, Rests or Teeth) D5410 Adjust Complete Denture Maxillary D5411 Adjust Complete Denture Mandibular D55 *Replace Missing/Broken Teeth D56 *Repair/Replace Broken Clasp D56 *Add Tooth To Existing Partial Denture D5660 *Add Clasp To Existing Partial Denture D57 *Reline Complete Maxillary Denture (Chairside) D5731 *Reline Complete Mandibular Denture (Chairside) D5740 *Reline Maxillary Partial Denture (Chairside) D5741 *Reline Mandibular Partial Denture (Chairside) D5 *Reline Complete Maxillary Denture (Lab) D1 *Reline Complete Mandibular Denture (Lab) PROSTHODONTICS - FIXED D60 *Implant Abutment D6010 Implant D6059 *Implant Crown D6190 Pre Surgical Index D6242 *Pontic Porcelain Fused to Noble Metal D62 *Abutment Porcelain Fused to Noble Metal ORAL SURGERY D7140 Ext Erupted Tooth/Exposed Root D7210 Surgical Extraction D72 Removal Impacted Tooth Soft Tissue D72 Removal Impacted Tooth Partial Bony D7240 Removal Impacted Tooth Completely Bony D72 Surgical Removal of Residual Root D7288 Brush Biopsy D7310 Alveoloplasty in Conjunction w/ext - Per Quad D73 Alveoloplasty Not in Conjunction w/ext - Per Quad D10 Incision & Drainage of Abscess 4 Per Site
4 Dental Specialist Schedule Dentists may add additional lab fees to discounted services with* ORAL SURGERY & PERIODONTICS D3410 Apico Anterior First Root D3421 Apico Bicuspid First Root D34 Retrograde Filling 1st Root D4210 Gingivectomy Per Quad D4249 Crown Lengthening D4260 Osseous Surgery - Per Quad D4263 Bone Graft Per Site D4273 Root Coverage Per Tooth D4274 Distal Wedge Per Site D4321 *Splinting D4341 Scaling & Root Planning - Per Quad D4910 Perio Maintenance D6010 Implant D60 *Implant Abutment D6059 *Implant Crown D7140 Simple Extraction D7210 Surgical Extraction D72 Surgical Extraction Soft Impaction D72 Surgical Extraction Partial Bony D7240 Surgical Extraction - Full Bony Impaction D72 Surgical Extraction Root Tip D7288 Brush Biopsy D7310 Alveoloplasty in Conjunction w/ext - Per Quad D73 Alveoloplasty Not in Conjunction w/ext - Per Quad D7410 Biopsy - Excision of Benign Lesion up to 1. cm D10 Incise And Drain Intraoral D7951 Sinus Lift Window D7951 Sinus Lift Osteotomy/Per Site D7960 Frenectomy D9310 Specialist Consultation , , ENDODONTIST D3310 Root Canal Anterior D33 Root Canal Bicuspid D33 Root Canal Molar D3410 Apico Anterior First Root D3421 Apico Bicuspid First Root D34 Apico Molar First Root D3426 Each Additional Root D34 Retrograde Filling 1st Root MISCELLANEOUS D2962 *Laminates / Veneers D4321 *Splinting D9110 Palliative Treatment Dental Pain - Minor Procedure D9215 Local Anesthesia D9940 *Niteguard D9951 Occlusal Adjustment-Limited In Office Whitening System (i.e. Zoom) ORTHODONTICS % Discount / UCR s PEDODONTICS % Discount / UCR s Any Service not listed on Discounted Schedule, please refer to office private fees. Patients Pay at Time of Service No Claims, No Waiting, No Limitations (888) Ext. 4
5 Dental Direct Discount Membership Program Participating Dentist Agreement / Terms & Conditions This Agreement ( Agreement ) is entered into between the undersigned dentist ( Participating Dentist ) and Dental Direct Benefits, by and on behalf of itself and its subsidiaries and affiliates ( Dental Direct Benefits ). I. General Provisions 1. Participating Dentist (General Dentist or Specialist) or Participating Group Practice agrees to provide Dental Services to Members and to provide such services in the same manner in which, and with the same availability as, Participating Dentist provides services to his or her other patients. Participating Dentist agrees to provide Dental Services without discrimination against any Members on the basis of participation in the Discount Membership Program, source of payment, age, sex, ethnicity, religion, sexual preference, health status or disability. 2. Participating Dentist represents and warrants that he or she is licensed to practice dentistry pursuant to the laws where he or she is practicing dentistry. Participating Dentist also represents and warrants that his or her license to practice dentistry and DEA registration, if applicable, are not suspended or revoked. Participating Dentist agrees that he or she will promptly notify Dental Direct Benefits in writing should either such license or registration be revoked, restricted, suspended or otherwise subject to disciplinary action by any government agency. Participating Dentist authorizes Dental Direct Benefits to obtain information concerning the undersigned s professional qualifications as well as to inquire within National Practitioner Data Bank about the undersigned s practice. 3. For purposes of this Agreement, Dental Services means a dental service or supply for which a benefit may be payable under the terms of a Discount Membership Program. Discount Membership Program means a group or individual dental care program that is administered by a third party partner. Member means an individual entitled to the Discount Membership Program. 4. Dental Direct Benefits may contract with persons or entities (including, without limitation, Dental Direct Benefits subsidiary or affiliated organizations, self administered or self funded programs providing dental care benefits, employers or insurers wishing to utilize the services of Dental Direct Benefits dental network) incorporating the terms and conditions of this Agreement. It is agreed that the other entity will succeed to all of Dental Direct Benefit s rights and obligations under this Agreement. 5. All Participating Dentists in the Discount Membership Program agree to accept as payment in full for Dental Services the amount shown in the attached assigned fee schedule (the Amount ). 6. Dental Direct Benefits shall have no obligation to Participating Dentist for any claims for Reimbursement Amounts not paid by or on behalf of a self funded group plan sponsor for which Dental Direct Benefits administers a Discount Membership Program. Dental Direct Billing reserves the right to change Reimbursement Amounts at any time upon notice to a Participating Dentist. 7. Members are responsible for all Dental Services that are not covered under the Discount Membership Program; Members are also responsible for all deductibles, co payments and coinsurance amounts required under the Discount Membership Program. Participating Dentist agrees to charge and collect any applicable co payments, coinsurance and/or deductible amounts as may be required. 8. Participating Dentist warrants that he or she has and shall maintain professional liability and comprehensive general liability insurance in amounts reasonable and customary for the Participating Dentist s location and specialty, at his or her sole cost and expense. Participating Dentist agrees to notify Dental Direct Benefits immediately of any termination or restriction of such coverage. Participating Dentist shall produce certificates of insurance. 9. Participating Dentist shall keep accurate and current dental files and records for each Member who is a patient. Participating Dentist agrees to comply with all applicable laws and regulations regarding the privacy and confidentiality of such records. Dental Direct Benefits may upon request with appropriate releases inspect and receive copies of dental records of Members without restriction. Participating Dentist shall make available such records to appropriate state and federal authorities and their agents involved in assessing the accessibility and availability of care or investigating grievances or complaints. 10. Except as provided herein, neither Participating Dentist nor Dental Direct Benefits may use the other party s symbols, trademarks or service marks in advertising or promotional materials or otherwise without the prior written consent of that party. The Participating Dental Direct Discount Membership Program Dentist agrees to have his or her name, specialty, office address, office telephone number and office hours listed in the Dental Direct Benefits dental directory of contracted dentists. 11. Participating Dentist agrees that when Dental Direct Benefits contracts with other persons or entities for use of Participating Dentist s services under this Agreement. Participating Dentist will provide services to Members of that other entity in accordance with the terms of this Agreement. In all events, however, Participating Dentist shall look for payment only to the particular entity that covers the particular services for which Participating Dentist seeks to be compensated (except for applicable deductibles, copayments or other obligations of Members). 12. Participating Dentist agrees to Dental Direct Benefit s periodic review of utilization, quality of care and peer review. 13. The parties agree to keep the confidential and proprietary information or trade secrets of each other in trust and confidence and agree that such information shall be used for the purposes contemplated in this Agreement. Without limiting the generality of the foregoing, it is agreed that all compensation arrangements between the parties and the identities of Members shall specifically be considered proprietary and confidential. II. Term and Termination 1. The term of this agreement shall begin on the Effective Date listed on the signature page of this Agreement and shall continue in effect until terminated by either party pursuant to the terms of this Agreement. 2. This Agreement may be terminated (i) without cause by either party by giving the other party thirty () days prior written notice, or (ii) immediately by Dental Direct Benefits if Participating Dentist s license(s) is/are revoked, suspended or restricted or if his or her professional liability insurance is terminated or restricted, or (iii) immediately by Dental Direct Benefits upon the death or disability of Participating Dentists. 3. If this Agreement is terminated, each party shall remain liable for any obligations or liabilities arising from activities carried on by it hereunder prior to termination, and Participating Dentist shall continue to provide Dental Services under the terms of this Agreement as if it had not been terminated for all courses of treatment of Members that began prior to the termination of this Agreement until such treatment is completed. III. Dispute Resolution 1. Dental Direct Billing and Participating Dentist agree to meet and confer in good faith to resolve any problems or disputes that may arise. 2. In the event that any problem or dispute arising under this Agreement and/or concerning the terms of this Agreement is not satisfactorily resolved pursuant to Section 1 above, Dental Direct Benefits and Participating Dentist will arbitrate such problem or dispute. Such arbitration shall be initiated by either party making a written demand for arbitration to the other party. The arbitration will be conducted by the American Arbitration Association under the Commercial Rules of the American Arbitration Association, unless otherwise mutually agreed in writing by Dental Direct Benefits and Participating Dentist. Participating Dentist and Dental Direct Billing agree that the arbitration results shall be binding on both parties in any subsequent litigation or dispute. IV. Miscellaneous 1. Participating Dentist shall be solely responsible to Members for the method or means by which Participating Dentist renders dental treatment or service to Members. Participating Dentist shall be solely responsible for any acts or omissions relating to the diagnosis and treatment of Members. Nothing herein shall be construed as granting Dental Direct Benefits the right to engage in the practice of dentistry. 2. The parties are independent contractors, and nothing in this Agreement is intended to create nor shall it be construed to create any employment, agency, joint venture or partnership relationship between the parties. Dental Direct Benefits shall have no dominion or control over Participating Dentist, the dentist patient relationship, participating Dentist s personnel or facilities, or Participating Dentist s services. 3. If any portion of this Agreement is found to be void or illegal, the validity or enforceability of any other portion shall not be affected. This Agreement shall be governed by the laws of the state of New York. Dental Direct Discount Membership Program 4. No waiver or any breach, privilege or provision hereunder shall be construed as a waiver of any other breach hereunder. 5. Any notice provided for in this Agreement shall be in writing, hand delivered, mailed by certified mail, or sent by a nationally recognized delivery service as follows: If to Dental Direct Benefits: To the address Shown on the Signature Page of this Agreement If to Participating Provider: To the first address listed at the end of this Agreement 6. This Agreement constitutes the entire agreement between the parties as to the subject matter hereof. This Agreement may be amended at any time during its term upon thirty () days prior written notice to Participating Dentist from Dental Direct Benefits. SIGNATURE Please sign and date below that you have read and agree to the terms provided in the Participating Dentist Agreement. Participating Dentist (type or print name) Signature Date Dental Direct Benefits
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