Get Provider Application Form - Western Dental

Filling out the Provider Application Form for Western Dental is an essential step for providers looking to establish their practice with the organization. This guide provides clear, step-by-step instructions to assist users in accurately completing the form online.

Follow the steps to successfully complete the Provider Application Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section I, Site Office Information. Provide your practice name, and indicate to whom the capitation checks should be issued (either to the doctor or practice). Fill in your suite number, address, city, state, office telephone and fax numbers, owner dentist name, social security number, practice type, email address, tax identification number (TIN), office manager name, and national provider identifier (NPI) number.
3. In Section II, Staffing, list all dentists practicing in your office by providing their first and last names, NPI numbers, social security numbers or TINs, specialties, year graduated, and license numbers.
4. Move to Section III, Patient Management. Indicate the languages spoken in your office, the number of new patients your practice can accept per month without additional dentists, and waiting times for new patient exams, hygiene appointments, and routine treatments. Specify whether emergency services are available 24/7, including details on emergency provisions and patient recall methods.
5. In Section IV, Equipment Management, confirm whether you have X-ray units and nitrous oxide. Specify if x-ray controls are permanently mounted, whether radiation equipment meets safety requirements, and if x-ray units are certified with expiration dates and certification numbers.
6. For Section V, Computerization, indicate if you submit claims electronically and if you have internet access.
7. In Section VI, Facility, describe the available parking types and detail the number of operatories, reception area seats, and square footage of your practice. Provide your days and hours of operation.
8. Section VII covers Internal Policies. Answer whether health education materials are available, if emergency medical kits are updated, if post-op instructions are documented, and detail other internal policies as asked.
9. Finally, Section VIII requires you to attach copies of essential documents for each provider listed in Section II, such as dental licenses, specialist licenses, DEA certificates, informed consent forms, proof of professional liability insurance, and CPR certifications. Make sure these documents are ready for submission.
10. After completing the form, thoroughly review all entered information for accuracy. Once confirmed, you may save changes, download, print, or share the completed form.

Complete your provider application form online today for efficient processing and a streamlined application experience.