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Need to update your information, file a claim, or sign up for direct deposit? We think these forms can help:

  • Electronic Funds Transfer authorization (Direct Deposit) – Complete this form and we’ll deposit all your payments directly into your bank account. You’ll receive your payments more quickly, avoid long lines at the bank, worry less about lost or stolen checks and help save trees, too. How you receive your claim statements won’t change unless you log in and choose a different method.
  • Notice of Address Change – Are you no longer providing dental care at a certain location? Is your entire office moving to a new location? Let us know in advance of any address changes so enrollees have access to your correct information, and we do not delay processing your claims.
  • Notice of Sale of Practice – Selling your practice? To make your sale as smooth as possible, start the process by filling out this form.  
  • Credentialing – We are required to confirm your professional and legal qualifications to treat enrollees. So, each provider is asked to complete this form during the initial application process and every three years thereafter. We keep all your information confidential.
  • Locum Tenens Provider Form – Complete this form to contract a credentialed provider as a Locum Tenens, replacing a provider for a temporary period of time, in the event of a disability or death.
  • Taxpayer Identification Number (TIN) Request Form – Dentegra uses your TIN to identify how to make claim payments to your office. This form is to update a TIN that is currently on file with us.
  • Office Information for Online Dentist Directory – We’ll advertise to potential applicants on your behalf; just another perk of being a provider in the Dentegra network! Tell us who works in your office and their credentials, your office location, contact information, languages spoken, etc.  
  • Dentegra Claim Form – Please consider sending us claims electronically. If your office is just not ready to send electronically, we have created a Dentegra claim form that allows you to fill in all claim information and includes our address to send the claim. 
  • Dentegra Provider Dispute Form – Complete this form to dispute a processing determination or other contract concern.

Register or log in now to instantly download these forms.