Follow the steps to fill out the Eyequest form efficiently.

1. Press the ‘Get Form’ button to access the Eyequest form and open it in your editor.
2. Begin by entering the primary practice information. Fill in the primary practice legal name, trade name (D/B/A), and complete the address fields, including county, city, state, and ZIP code. Ensure that the telephone number and email address are accurately recorded.
3. Specify whether your practice is a solo or group practice and provide the contact person’s name and title.
4. List the individual practitioners in the practice. For each practitioner, include their name, Medicaid ID number, and title (O.D., M.D., D.O.).
5. Complete the practice demographics section by answering the yes/no questions regarding your practice's acceptance of Medicare and Medicaid patients, participation in any Medicaid Managed Care Plans, and whether a doctor is on-call 24/7.
6. Provide information about whether other languages are spoken at the practice, dispensing of glasses, and if the practice offers evening or weekend hours for patient care.
7. In the additional information section, include any details you believe are relevant for consideration in joining the network.
8. Finally, inform Eyequest about the status of your provider application by marking the appropriate option regarding acceptance into the panel.
9. Once you have completed all sections of the form, submit it by facsimile to Eyequest at 1-888-696-9552 or via email at eyeQuest@dentaquest.com. Remember to allow 4-6 weeks before checking your application status.

Complete your documents online today to enhance your practice's opportunities.