Entity Intake Form

Your information is secure. This form is encrypted and used only for credentialing purposes.

ENTITY INFORMATION

How did you hear about Credentialing Genie?

What is your phone number?

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

Billing Address for Credentialing (EOBs and payments will be mailed here) Street Address

City

State / Province

Postal / Zip Code

Practice Owner Information

Owner Name

Owner's Date of Birth

Owner's SSN

Gender *

Is the practice owner a licensed dentist? *

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 *

Dental school other degree awarded *

Owner's Signature

Drag and Drop file here

Primary Office Location

Primary Office Address Street Address

City

State / Province

Postal / Zip Code

Office Phone

Office Fax

Languages other than English spoken by office staff

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

EFT Payment setup

I do not want to sign up for EFT payment

I want to sign up for EFT payment

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

Name of person filling out this form

Confirmation Email (This email will receive your confirmation) *

Authorized signature

Thank you

Entity Intake Form