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Has sold the above practice to P U C H A Purchaser s signature Date I seller understand that pursuant to the foregoing sale and in accordance with my Participating Dentist Agreement with Delta Dental all payments made by Delta Dental for Attending Dentist s Statements submitted by me for services dated on or before will be reported by Delta Dental to the Internal Revenue Service as my earnings. NOTICE OF SALE OF PRACTICE This is to notify Delta Dental that pursuant to an agreement Name License number Name of practice Social Security number L Address of practice TIN S E R print or type street City State ZIP code Seller s signature Date If there is more than one seller the above information must be provided on all sellers with accompanying dated signatures for each seller you may use the back of this form. initials I purchaser understand that Attending Dentist s Statements for services provided after date of sale must be submitted under my name and will be payable to me according to my Participating Dentist Agreement with Delta Dental or if I do not have a Participating Dentist Agreement with Delta Dental will be payable to the enrollee according to the terms of the enrollee s group dental care contract. Assignment of Payments Purchaser has purchased the accounts receivable from Seller Please return this form to your local Delta Dental Delta Dental of California ATTN Dentist Network Administration and Contracting P. O. Box 537010 Sacramento CA 95853-7010 Or dentistservices delta*org 1130 Sanctuary Parkway Suite 600 Alpharetta GA 30009 Or dnac ddic*delta*org One Delta Drive Mechanicsburg PA 17055-6999 Or ddpdentistservices deltadentalpa*org E Delta 1139 61922 Rev* 12/10. initials I purchaser understand that Attending Dentist s Statements for services provided after date of sale must be submitted under my name and will be payable to me according to my Participating Dentist Agreement with Delta Dental or if I do not have a Participating Dentist Agreement with Delta Dental will be payable to the enrollee according to the terms of the enrollee s group dental care contract. Assignment of Payments Purchaser has purchased the accounts receivable from Seller Please return this form to your local Delta Dental Delta Dental of California ATTN Dentist Network Administration and Contracting P. Assignment of Payments Purchaser has purchased the accounts receivable from Seller Please return this form to your local Delta Dental Delta Dental of California ATTN Dentist Network Administration and Contracting P. O. Box 537010 Sacramento CA 95853-7010 Or dentistservices delta*org 1130 Sanctuary Parkway Suite 600 Alpharetta GA 30009 Or dnac ddic*delta*org One Delta Drive Mechanicsburg PA 17055-6999 Or ddpdentistservices deltadentalpa*org E Delta 1139 61922 Rev* 12/10. initials I purchaser understand that Attending Dentist s Statements for services provided after date of sale must be submitted under my name and will be payable to me according to my Participating Dentist Agreement with Delta Dental or if I do not have a Participating Dentist Agreement with Delta Dental will be payable to the enrollee according to the terms of the enrollee s group dental care contract. Assignment of Payments Purchaser has purchased the accounts receivable from Seller Please return this form to your local Delta Dental Delta Dental of California ATTN Dentist Network Administration and Contracting P. O. Box 537010 Sacramento CA 95853-7010 Or dentistservices delta*org 1130 Sanctuary Parkway Suite 600 Alpharetta GA 30009 Or dnac ddic*delta*org One Delta Drive Mechanicsburg PA 17055-6999 Or ddpdentistservices deltadentalpa*org E Delta 1139 61922 Rev* 12/10..

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