Dental Network Consultant Request Form

Use this form for initial requests only. Uploading a complete and signed provider authorization form is required prior to form submission. A blank copy of the authorization form can be found here.

All required fields are marked with: *

Step 1: Upload the completed authorization form:

Provider authorization file upload *

Multiple authorization files, each less than 3 MB, can be uploaded.
Allowed types: pdf, jpg, png, heif, raw

Step 2: Complete Consultant Information:

Consultant company *

Consultant name *

Consultant email address *

Nature of request *

If you selected other above, please explain (255 characters max).

Step 3: Complete Provider Information:

Additional providers can be added by using the +/- buttons.

Provider information *

Provider information
Tax ID * Provider NPI * Provider name * Provider address * City * State * ZIP code *

Additional details or questions