Dental Group Credentialing Form

Entity Information

Affiliated locations

Practice owner information

EFT Payment Setup

Insurance Networks to Credential With

ENTITY INFORMATION

How did you hear about Credentialing Genie?

What is your phone number?

Is this a new office or an office you have purchased from someone else?

Please upload your entity's W-9

Drag and Drop file here

Practice Name

Legal Business name on W-9

TAX ID Number

Group NPI Number

Office manager email address

Headquarter Billing Address (the insurances will mail EOBs and payment to this address) Street Address

City

State / Province

Postal / Zip Code

Affiliated locations

How many practice locations are associated with this Tax ID for credentialing purposes?

📍 Location 1 | Tax ID:

Primary Office Address Street Address

City

State / Province

Postal / Zip Code

Office Phone

Office Fax

Languages other than English spoken by office staff

Practice owner information

Owner Name

Gender *

Owner's Date of Birth

Dental license number

Dental license expiration date *

DEA license number *

DEA expiration date *

Owner's NPI

Owner's SSN

Specialty *

Area of Specialty *

Orthodontist

Oral Surgeon

Periodontist

Prosthodontist

Endodontist

Pediatric Dentist

Specialty school name *

Specialty school's city *

Specialty school's state *

Specialty school's postcode / ZIP *

Specialty school start date *

Specialty school completion date *

% of Ownership

Dental degree awarded *

DMD

DDS

Owner's Signature

Drag and Drop file here

Current copy of DEA license *

Drag and Drop file here

Current copy of dental license *

Drag and Drop file here

List the names of the dentists you would like to credential for this location.

EFT Payment Setup

Account Legal Name

Account Type

Name of Financial Institution

Account Number

Bank Routing Number

Attached Voided Check (upload file)

Drag and Drop file here

ENTITY AUTHORIZATION AGREEMENT

I, ..., the authorized representative of , grants Credentialing Genie (CMO Pacific LLC) permission to act on behalf of our dental practice for all credentialing and payer enrollment purposes. This authorization includes, but is not limited to:

Accessing, updating, and maintaining the practice’s CAQH profile and any other payer-required credentialing databases
Preparing, signing, and submitting credentialing applications to selected insurance payers on behalf of the practice and its providers
Communicating directly with insurance companies, credentialing departments, and payer representatives regarding applications, updates, and supporting documentation
Using the practice’s business information (including NPI, EIN, legal address, tax details) and provider information as required for credentialing
Receiving, responding to, and managing all credentialing-related correspondence from payers

HIPAA Compliance: Credentialing Genie will maintain the confidentiality, integrity, and security of all submitted information in full compliance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable privacy laws. Information will only be used or disclosed as required to complete credentialing and enrollment with insurance payers.

E-Sign Consent: By typing my name below and checking the acknowledgment box, I agree that my electronic signature has the same legal force and effect as a handwritten signature under the U.S. E-Sign Act.

This authorization remains in effect until credentialing services are completed or revoked in writing. I certify that I am authorized to bind this entity and that all information provided is accurate and complete.

I have read and agree to the Authorization Agreement above.

Authorized Representative Name (Typed Signature)

Title

Date Signed

Authorized Personnel Submission

Confirmation Email (This email will receive your confirmation)

Name of person filling out this form

Authorized signature

Thank you

Dental Group Credentialing Form