Please Fill Your Intake Form

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To ensure that we have all the necessary information to provide you with the best service, please fill out this intake form completely. If you have any questions, feel free to reach out to our support team.

Section 1: Practice Information

Section 2: Contact Information

Section 3: Practice Details

Type of Dental Practice

Section 4: Dental Insurance Information

Are you contracted with any dental insurance companies? If yes, please list the names of the companies:
Do you accept PPO, HMO, or both?*
If applicable, are you a provider for state dental insurance programs such as Denti-Cal (California) or similar programs in other states?

Section 5: Billing Information

Are you currently outsourcing dental billing?  If yes, why are you considering changing providers? Briefly describe any challenges or issues you have faced with dental billing in the past:
Section 6: Services Required Please indicate the specific services you require assistance with:

Section 7: Additional Information

Are there any unique billing requirements or considerations for your practice that we should be aware of?

Please submit the completed intake form. Our team will review the information provided and get in touch with you to discuss the next steps.

We look forward to working with you!