DHP Office Verification Form (OVF)

Doctor / Owner Name

Email Address

Phone Number

Your Role at the Practice Your Role at the PracticeDHP RepOwner / DoctorAssociate DoctorOffice ManagerExecutive / Group LeadershipCPA/CFPOther

Practice Name

Years in Business Years in BusinessJUST PURCHASED/PURCHASING1-56-1011-2021+I WANT TO SELL MY PRACTICE

Practice Address

City

State StateALAKARAZCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNCNDNENVNHNJNMNYOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Practice TIN / EIN

Doctor NPI Number

DHP Rep (Alphabetical by First Name) DHP Rep (Alphabetical by First Name)Aaron LucienAaron PodnarAaron VerasteguiAndrea MergesAshley AyersBill BalinskiBob HollowayBrandan MendenhallBrenda ThiryChad GordonChloe SimsChris EmersonChris YoungDanielle KruegerDarrell DurieDeara NikolouzosDenise SmolikDominic RealeDon FiguraEd KeyserFrancisco AguilarGary GleasonGreg LevittHarry GengHector GonzalezHunter JustusJ HavlicekJeff EllisJennifer LeCaptainJennifer LucienJesse HankeJustin ReynoldsKeith TaylorKelly YarboughKevin BenevidesKimberly NelsenKylee MagnusonLaDeana DeClarkLevi AndersonMark LeCaptainMarty HullMatt CurryMichael GoolsbyMike AusloosMiriam HernandezNaveed MohammedPaula BlockRyan FrisqueSandy JonesScott PeCoreSherry WoldSteve DesautelSteve WardStuart SicklesTanner JustusTim ZyskowskiTodd RodwellTom KelmTonia CanovaVince GiardinaOTHER

Practice Management Software Practice Management SoftwareCurveDenticon/Planet DDSDentrixDentrix AscendEaglesoftEasy DentalOpen DentalSoftDentOther

If Other, Please List Your Practice Management Software

Have you previously worked with another PPO Company? Have you previously worked with another PPO Company?YESNO

If yes, which PPO Company did you use?

Do you have copies of Recent EOBs available? Do you have copies of Recent EOBs available?YESNONOT SURE

Which carriers do you need help with?

Approximate Annual Production

Approximate Annual Write-Offs

Do you have multiple Doctors in the practice? Do you have multiple Doctors in the practice? YES NO

Do you have multiple practice locations? Do you have multiple practice locations? YES NO

Are you planning to add an associate in the next 12 months? Are you planning to add an associate in the next 12 months? YES NO NOT SURE

Are you planning to add chairs or expand the practice? Are you planning to add chairs or expand the practice? YES NO NOT SURE

What would you like Solutions 101 to help you solve?