NAME*

Email ADDRESS*

YOUR ROLE AT PRACTICE* YOUR ROLE AT PRACTICE*Owner/DoctorDoctorOwnerOffice ManagerInsurance CoordinatorCPA/CFPOther

PHONE*

Practice/Office Name*

YEARS IN BUSINESS* YEARS IN BUSINESS*JUST PURCHASED/PURCHASING1-56-1011-2021+I WANT TO SELL MY PRACTICE

PRACTICE ADDRESS*

CITY*

State* State*ALAKARAZCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNCNDNENVNHNJNMNYOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

ZIP CODE*

DOCTORS NAME*

Practice Management Software Used* Practice Management Software Used*CurveDenticon/Planet DDSDentrixDentrix AscendEaglesoftEasy DentalOpen DentalSoftDentOther

Practice Management Software

I Have Used Another PPO Company I Have Used Another PPO CompanyYESNO

Name of Other PPO Company Used

Carriers of Concern Carriers of Concern Aetna Ameritas BlueCross/BlueShield Careington Cigna Delta Dental DenteMax DHA/SunLife Guardian GEHA/Connection Dental Humana Medicare/Medicaid MetLife Principal United Concordia United Healthcare Other ALL

I Need I Need Talk Tracks Patient Notifications To Add A Carrier To Drop A Carrier Negotiations Optimization Fee Schedule Assistance On Site Training Patient Retention More Patients New Patients Fewer Patients Compliance Tracking Credentialing A Guarantee ALL OF IT

I HAVE ACCESS TO MY EOBS I HAVE ACCESS TO MY EOBS ELECTRONICALLY PAPER COPIES ELECTRONIC AND PAPER I CANT ACCESS THEM

Tell us what you are wanting/needing to accomplish