OFFICE VERIFICATION FORM (OVF)

PERSON COMPLETING FORM*

Email (OFFICE OR PERSONAL)*

OFFICE CONTACT PERSON* OFFICE CONTACT PERSON*SAME AS PERSON COMPLETINGOTHER

PROJECT CONTACT PERSON

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

PHONE (OFFICE OR CELL)*

Practice/Office Name*

PRACTICE DBA (IF APPLICABLE)

PRACTICE ADDRESS*

CITY*

State* State*ALAKARAZCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNCNDNENVNHNJNMNYOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

ZIP CODE*

PRACTICE TIN/EIN #

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

DOCTORS NAME*

DOCTORS NPI #*

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 Company*YESNO

Name of Other PPO Company Used

ADD GROUP NPI # ADD GROUP NPI # YES

GROUP NPI#

ADD ANOTHER DOCTOR ADD ANOTHER DOCTOR ADD ANOTHER DOCTOR

ADDITIONAL DOCTOR

ADD ANOTHER NPI #

I HAVE ADDITIONAL DOCTORS TO ADD* I HAVE ADDITIONAL DOCTORS TO ADD* YES NO

I HAVE MULTIPLE LOCATIONS* I HAVE MULTIPLE LOCATIONS* YES NO

I HAVE AN ADDITIONAL TIN/EIN* I HAVE AN ADDITIONAL TIN/EIN* YES NO

OUR OFFICE RECEIVES CAPITATION PAYMENTS* OUR OFFICE RECEIVES CAPITATION PAYMENTS* YES NO