Get Medpro Dental Form

This guide provides a step-by-step approach to filling out the Medpro Dental Form online. Designed for dental professionals, this comprehensive guide will help you navigate each section with clarity and confidence.

Follow the steps to complete your application effectively.

1. Click ‘Get Form’ button to obtain the Medpro Dental Form and open it in your preferred editor.
2. Begin with the general information section. Provide your last name, first name, date of birth, middle initial, suffix, social security number (if desired), National Provider Identifier (NPI), email, business fax, business phone, and residence/cell phone. Ensure all fields are filled accurately and legibly.
3. Next, detail your practice locations. Start with the primary location, specifying the combined percentage of practice for each location, and indicate whether it is a hospital, office, or residence. Repeat for any additional locations.
4. Complete the preferred billing and correspondence address. Indicate which location number from the previous section applies or provide an alternative address.
5. Proceed to the educational background. Answer whether you are entering private practice for the first time and if you have completed a risk management education course within the last twelve months. Provide details about your dental school, including the name, city, degree, and duration.
6. In the practice information section, indicate the states where you hold a dental license and describe your practice status, including previous locations and any gaps in practice. Mention your average weekly patient numbers and whether you belong to any dental societies.
7. Fill in the rating information by checking your present specialty and the procedures you will perform. Note your percentage of practice devoted to each type of procedure.
8. Provide anesthesia information regarding your practice. Specify if you use conscious sedation or general anesthesia, or indicate if this section does not apply to you.
9. Continue with the additional professional information, disclosing any treatments involving non-federal prison inmates, legal issues, or limitations related to your ability to practice dentistry.
10. Complete the practice organization information, detailing your employment status, entity type, and affiliations.
11. In the loss information section, report any claims or incidents related to professional services that might lead to a claim.
12. Detail your desired coverage and effective dates. List previous insurers and explain any gaps in coverage.
13. Initial the state statutory requirement section and read/sign the final declaration. Make sure all information is true and accurate.
14. Once all sections are completed, save your changes, download or print the form, and share it as necessary.

Complete the Medpro Dental Form online today to ensure your professional liability coverage is in place.