Get Upmc Dental Advantage Form

Filling out the Upmc Dental Advantage Form online is a straightforward process that enables dental practitioners to apply for participation within the UPMC Dental Advantage network. This guide will walk you through each step required to complete the form accurately and efficiently.

Follow the steps to complete the Upmc Dental Advantage Form online

1. Press the ‘Get Form’ button to access the Upmc Dental Advantage Form and open it in your designated online editor.
2. Identify the type of application you are submitting by checking the appropriate box: whether it is a new dental office application, a change of contact information, adding an office location, or adding a provider.
3. Fill in the Dental Office Information section, including the primary office name, email, street address, suite number, city, state, tax ID number, fax number, payee name, and credentialing contact person.
4. Specify the legal status of the dental office by selecting from options such as corporate, individual, sole proprietorship, partnership, or non-profit organization.
5. List any languages spoken by the provider or staff that are not English, and indicate the hours of operation for each day of the week.
6. Proceed to the Dentist Application section and document personal information, including last name, first name, middle initial, degree, gender, and social security number.
7. Indicate the type of affiliation requested and the dental specialty you are applying for, if applicable.
8. Complete the sections related to licensure, DEA, and identification numbers, providing details about your current insurance carrier, board certification status, and hospital privileges if required.
9. Document your educational and training history comprehensively, beginning with your dental school and including all relevant post-graduate training.
10. Detail your employment history, ensuring there are no gaps exceeding six months, and provide additional information where necessary.
11. Answer the conflict of interest and declarations sections, providing thorough responses to all questions and indicating any necessary attachments.
12. Review the applicant's affirmation and release of information section. Sign and date it accurately, assuring all provided information is truthful and complete.
13. Once you have filled out all sections, save your changes, and choose to download, print, or share the completed form as needed.

Start filling out your Upmc Dental Advantage Form online today!