Entity Intake Form

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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 (Type 2 NPI)

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.

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

EFT Payment setup

I do not want to sign up for EFT payment

I want to sign up for EFT payment

Insurance Plans for Credentialing

ENTITY AUTHORIZATION AGREEMENT & DISCLAIMERS

I have read and agree to the Authorization Agreement.

I have read and agree to the Fee Schedule & Reimbursement Disclaimer.

I have read and agree to the Application Submission, Cancellation & Withdrawal policy.

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)

Client Acknowledgment

Electronic Acceptance Record

Entity Authorization Agreement

Practice / Office	Tax ID
Practice Address	Document Status Pending Agreement

I certify that I am authorized to act on behalf of the practice/entity identified above. I authorize Credentialing Genie (CMO Pacific LLC) to act on behalf of the practice for insurance credentialing and payer enrollment purposes, including:

Preparing and submitting credentialing and enrollment applications;
Using the practice's Tax ID/EIN, Type 2 NPI, addresses, ownership information, W-9, and other required business information;
Communicating with insurance companies and payer representatives regarding applications and enrollment;
Submitting supporting documents provided or approved by the practice;
Adding authorized providers and locations to payer networks; and
Receiving and responding to credentialing-related requests and correspondence.

Client Responsibility

The practice is responsible for providing accurate and current information and authorizes Credentialing Genie to rely on that information when completing applications.

Duration & Revocation

This authorization remains valid while Credentialing Genie is providing services unless revoked in writing. Revocation does not automatically cancel applications already submitted to an insurance payer.

Client Acknowledgment

Electronic Acceptance Record

FEE SCHEDULE & REIMBURSEMENT DISCLAIMER

Practice / Office	Tax ID
Practice Address	Document Status Pending Agreement

Credentialing Genie's service is limited to assisting with the preparation, completion, submission, and follow-up of credentialing and enrollment applications based on the information provided by the client.

Credentialing Genie does not determine, negotiate, guarantee, or control the fee schedule or reimbursement rates offered by any insurance company, health plan, dental plan, network, or third-party administrator unless a separate fee schedule negotiation service has been specifically purchased.

Each insurance payer makes the final decision regarding:

Approval or denial of the credentialing or enrollment application;
Participation in a particular network, plan, or product;
The effective date of participation;
The provider or practice's assigned fee schedule; and
Reimbursement rates and contractual terms.

Fee schedules and reimbursement rates may vary based on factors determined solely by the payer, including geographic area, provider specialty, practice location, network, insurance product, market conditions, and the payer's internal policies.

Credentialing Genie is not responsible for the fee schedule or reimbursement rates assigned by the insurance payer after credentialing or enrollment approval. Submission of an application through Credentialing Genie does not guarantee any particular reimbursement rate, fee schedule, network participation, or financial outcome.

Client Acknowledgment

Electronic Acceptance Record

APPLICATION SUBMISSION, CANCELLATION & WITHDRAWAL

Practice / Office	Tax ID
Practice Address	Document Status Pending Agreement

Once Credentialing Genie submits an application to an insurance company, dental plan, health plan, network, or third-party administrator, the application is considered in process and is no longer under Credentialing Genie's control.

The insurance payer may begin reviewing, processing, or approving the application immediately after submission.

IMPORTANT:

A cancellation request does not immediately stop payer processing and does not guarantee that the application will not be approved.

If the client requests cancellation or withdrawal after an application has been submitted:

Credentialing Genie will make a reasonable effort to notify the insurance payer and request withdrawal or termination of the application.
Cancellation or withdrawal is not immediate and cannot be guaranteed.
The payer may have already processed or approved the application before receiving or completing the cancellation request.
If the provider or practice has already been approved or enrolled, the payer may require a separate network termination or dis-enrollment process.
Termination or dis-enrollment may take additional time depending on the payer's policies and processing timelines.
Credentialing Genie cannot control the effective date of cancellation, withdrawal, termination, or dis-enrollment.

SERVICE FEE RESPONSIBILITY: The client remains responsible for Credentialing Genie service fees for applications that have already been prepared and submitted, regardless of whether the client later requests cancellation or withdrawal.

Credentialing Genie is not responsible for delays, approvals, network participation, or other actions taken by the insurance payer before the payer completes the client's requested withdrawal or termination.

Thank you

Entity Intake Form