Get Express Scripts Dental Provider Enrolment Form

Completing the Express Scripts Dental Provider Enrolment Form online is essential for dental providers seeking to enroll and receive payments under the Non-Insured Health Benefits (NIHB) Program. This guide will walk you through each component of the form to ensure a smooth and efficient enrollment process.

Follow the steps to complete your enrollment form effectively.

1. Press the ‘Get Form’ button to access the Enrolment Form and open it in your preferred editing tool.
2. Fill out your dental provider information, including your unique provider number, language preference, surname, first name, license number, specialty, and communication preferences for general communication and predetermination letters.
3. Indicate your status in the clinic by selecting the appropriate option: Associate, Owner/Owner Partner, Salary, or Per Diem Dental Professional.
4. Provide your clinic or office information, including main and additional office details if applicable. This includes entering the effective date, status, Office ID, clinic name, address, phone numbers, and email addresses.
5. Complete the payment information section for electronic funds transfer (EFT). Provide your bank details, including bank name, branch name, and account number. Ensure to attach a void cheque or an official bank letter as specified.
6. Review the terms and conditions at the end of the form to understand your responsibilities as a provider and confirm your understanding by signing the form.
7. Once the form is completely filled out and signed, save your changes, and then download, print, or share the completed form as needed.

Complete your Express Scripts Dental Provider Enrolment Form online and streamline your enrollment process today!