RE-CREDENTIALING PROFILE ATTESTATION: All information on this profile is required for continued membership. Failure to provide required information will impact your membership status with Delta Dental of Washington. Provider Information Name: WA State License #: Do you have or are you eligible for a DEA Permit: YES DEA #: NO* please attach DEA Waiver Other State License #/State: Provider s Email Address: Type 1 (Individual NPI): Type 2 (Organizational NPI): ADA-Recognized Specialty (select only one): General Practitioner Periodontics Endodontics Oral Surgery Pediatrics Prosthodontics Orthodontics Education Dental School: Graduation Year: Degree: Graduate/Residency Dental Program: Graduation Year: DDS DMD MD MDS MSD BSDH BCHD RDH Has there been any additional degrees completed since your last re-credentialing application? * *If please attach certificate and complete the following information: School Name: Schooling Completed: Medicare Participation: I ve enrolled in Medicare I ve opted out of Medicare I have neither enrolled nor opted out of Medicare Do you follow the current recommendations of the American Dental Association and the Centers for Disease Control (CDC) regarding infection control as well as meet OSHA/WISHA requirements? Do you have Hospital privileges? (*If, attach a verification letter from the hospital) * Do you have current Malpractice insurance? (please attach a copy) RECRED062017
For the below questions, if you check, you must include a brief description on a separate sheet of paper and submit with this form. Are there any reasons for any inability to perform the essential function of the position, with or without accommodations? Has your license to practice dentistry in any jurisdiction been voluntarily surrendered, limited, suspended, or revoked? Have you ever been suspended, fined, disciplined, or otherwise sanctioned, restricted or excluded for any reasons, by Medicare, Medicaid, Office of Inspector General (OIG) or any public program or is any such action pending or under review? Have you been subject to review, challenges, and/or disciplinary action, formal or informal, by an ethics committee, licensing board, dental disciplinary board, professional association or education/training institution? Have you been found by a state professional disciplinary board to have committed unprofessional conduct as defined in applicable state provisions? Have you had any malpractice claims, suits, or settlements? Are you currently, or have you ever been, addicted to or excessively use alcohol, drugs, or toxic or foreign agents that would limit or adversely affect the performance of your professional duties or responsibilities? Do you have any history of felony convictions? Have you ever been, or are you now in the process of being denied, revoked, terminated, suspended, restricted, reduced, limited, sanctioned, placed on probation, monitored, or not renewed, or have you voluntarily or involuntarily relinquished, withdrawn, or failed to proceed with an application for clinical privileges at any facility, including hospitals in order to avoid an adverse action or to prelude an investigation or while under investigation relating to professional competence or conduct? Dentist Rights > The dentist has the right to review all information obtained during the re-credentialing process. > The dentist has the right to correct any erroneous or variant information obtained during the re-credentialing process. > The dentist may request the initial application be revisited if corrections are made within 180 days of the recredentialing decision, or may re-apply if the 180 day time requirement has lapsed. I hereby certify that the information requested by Delta Dental of Washington and provided herein is truthful, correct and complete in all respects. I further understand that the submission of false or misleading information, or the withholding of relevant information, is grounds for termination as a participating dentist with the dental plan. I hereby agree to notify Delta Dental of any changes in the above information, including changes in my malpractice coverage. Doctor Signature RECRED062017
AUTHORIZATION FOR RELEASE OF INFORMATION I authorize Delta Dental of Washington and their personnel to contact professional liability carriers, schools and universities, and other persons or entities, to obtain information concerning my professional qualifications, including education, competence, ethics and other information pertinent to providing dental services. I hereby release all parties and persons connected with any requests for information from all claims, liabilities, and damages for whatever reason arising out of furnishing such information. This authorization is required in order to perform the verifications required for credentialing. You must be credentialed in order to become a Delta Dental member dentist. To avoid a delay in processing your application, please be sure to sign and return the authorization along with your other application forms. Doctors Signature Dentist Name (typed or printed)
DEA Release Providers who are eligible to write prescriptions must have a valid and current DEA in each state where the care is provided. If you do not have a DEA Certificate inside the state of Washington or if your DEA Certificate is pending, you must complete and submit this form. If any time after completing this form, you apply for and receive a Washington DEA certificate, please fax the certificate to 206-985-4764. Provider s name: Dental license number: The following provider will write prescriptions for patients within my practice: Name of prescribing provider: Signature of prescribing provider: Prescribing provider s DEA #: Prescribing provider s License #: Signature of provider completing form: Printed Name: :
AUTHORIZATION FOR PROFESSIONAL LIABILITY CERTIFICATE I hereby authorize release of the following professional liability insurance information to Delta Dental of Washington. My professional liability coverage provided by: Insurance company name Address City, State, Zip Phone Fax Email Policy Number Please produce an additional certificate of insurance coverage for: Delta Dental of Washington P.O. Box 75688 Seattle, WA 98175 The certification should be mailed to Delta Dental of Washington at each renewal until otherwise notified or upon termination of coverage. Doctors signature Doctors name License number APLCR-52017