Provider Representative Contact Form

Dental Services Representative Contact Form

Please note: This form is to be used by dentists and other dental professionals to contact their assigned dental services representative. Physicians, other professional providers or medical facilities should contact your provider relations representatives & consultants. Vision, chiropractic and other complementary and allied professionals should contact their allied services representative. Mental health and chemical dependency professionals should contact their allied services representative. Members should contact customer service. The results of this form are encrypted and sent to our secure server for your privacy. Your form will be sent directly to your provider service representative. Please allow up to five business days for a response. For a more immediate response, please phone your provider services representative directly. An asterisk (*) indicates a required field.
My question/issue concerns the following:
	Participating Dental Agreement
	My question/issue is:
	Specific claim question
	My question/issue is:
	Dental Policy
	My question/issue is:
	General billing and coding methods relating to:
		(please describe)
	I have a change to my provider information
		(please describe)
	Other	(please describe)
*How would you prefer to be contacted?
	Phone
	Email

Your details:
*	Name:
*	Email:
*	Phone number:
*	Office/Practice name:
*	Office/Practice address:
*	Tax ID:


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