Practices with a Pair Dental Specialist Credentialing Step 1 of 8 0% Practice Owner's Name* First Last Email* Date of Birth* Month Day Year Practice Name* Practice Website Practice Phone Number*Fax Number*Practice Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NPI Type I* Practice Owner'sNPI Type II* Practice NPIState of Licensure* State State License Number* Expiration Date* MM slash DD slash YYYY Texas Provider Identifier NumberTPI How are emergencies handled in your practice? (CPR, Portable Oxygen, Medical Emergency Kit, etc.) Number of General Dentists in your Practice*Number of Dental Assistants in your Practice*Number of Hygienists in your Practice*Does your practice have any of the following in-house specialists? Oral Surgeon Orthodontist Periodontist Endodontist Prosthodontist Pedodontist Other Number of Specialists in your Practice*Number of Lab Technicians in your Practice*Number of Receptionists in your Practice*Languages spoken by staff, other than English Arabic Chinese Farsi French Korean Russian Spanish Tagalog Vietnamese Other Translation services available?* Yes No Type of payment accepted* Cash Credit card Personal check 3rd party financing (ie CareCredit) In-house payment plan Office Manager's Name First Last Office Manager's PhoneOffice Manager's Email Do you have an answering service?* Yes No Emergency hotline number?Current wait times for an initial visit(in days)Current wait times in lobby(in minutes)Current wait time for a routine visit(in days)Current wait time for an emergency visit(in days)Current wait time for a hygiene visit(in days)Number of OperatoriesDo you have a recall system in place?* Yes No Please describe your recall system Total number of active patients currently in your practiceWill you accept new patients?* Yes No Maximum number of new patients you can acceptOffice policy for broken appointments Facility features: IV Sedation Non-IV Sedation Wheelchair Accessibility Parking Provided Free Parking Child Play Area Sterilization Methods: Autoclave Chemiclave Dry Heat Cold Sterile Other Are office protocols for infection control in compliance with current CDC/OSHA guidelines?* Yes No Frequency of instrument sterilization* Average number of patients seen dailyNumber of chairs in your waiting roomDo you accept medicaid/medicare assignment? Yes No How do you submit claims?* Paper Electronically Do you prescribe medication?* Yes No DEA Number (Practice Owner) DEA Expiration Date MM slash DD slash YYYY Wheelchair Accessibility Features* Doorways and entrances to the building and office are at least 32" wide Hallways are at least 36" wide, with sufficient room for a wheelchair to make necessary turns There is enough room for a wheelchair user to travel from the waiting area to the treatment area. The restroom has an accessible doorway, at least 48" of clear floor space, and grab bars to allow transfer from/to wheelchair The building or office is accessible by more than stairs or a steep slope. If the building has parking facilities, there are parking spaces reserved for people with disabilities. Please upload a copy of your practice's W9*Max. file size: 20 MB.https://w9form-online.com/Would you like Synergy to book your specialist for treatment days prior to credentialing completion? Yes No Is this practice a new purchase? Yes No Please upload a bill of sale here:Max. file size: 20 MB. Hours: Monday Open* Hours: Monday Close* Hours: Tuesday Open* Hours: Tuesday Close* Hours: Wednesday Open* Hours: Wednesday Close* Hours: Thursday Open* Hours: Thursday Close* Hours: Friday Open* Hours: Friday Close* Hours: Saturday Open* Hours: Saturday Close* Hours: Sunday Open* Hours: Sunday Close* Please make your insurance selections here:* Aetna PPO Ameritas PPO Anthem BC Prudent Buyer PPO Anthem BC Prudent Buyer (SmileNet/Discount Program) PPO Anthem BC 100, 200, 300 PPO Careington PPO Cigna PPO Connection/GEHA PPO Delta Dental of CA Premier Dentegra PPO Dentemax PPO Dental Benefit Providers / United Healthcare PPO Dental Health Alliance (DHA) / Fortis / Assurant PPO / Sun Life Financial First Dental Health PPO First Dental Health EPO First Dental Health ACCESS Guardian PPO Humana PPO MetLife PPO Principal PPO Zelis Dental Network PPO Aetna HMO United Concordia PPO: NFFS Anthem BC Dental Net HMO Anthem BC Select HMO Anthem BC Senior Secure HMO Anthem BC Golden West HMO California Dental Network (CDN) HMO Cigna HMO Dental Benefits Providers / United Healthcare HMO DeltaCare USA HMO Dental Health Services (DHS) Guardian HMO / Managed Dental Guard Liberty HMO MetLife Safeguard United Concordia (UCCI) HMO UDC / Fortis / Assurant HMO Please include any other insurance plans you would like to inquire about credentialing: