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Office Profile

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Who should we contact if we have questions about your application?

Service Office Information

Can Fax Receive PHI?

Service Office Detail

Does the office have Public Transportation Access?
Handicap accessible exam rooms?
Is the office Handicap Accessible?
Handicap accessible equipment?
Handicap accessible lifts?
Does the office use Electronic Health Records?
Does the office offer TeleHealth Services?
Handicap / wheelchair access to building?
Does Your Office Provide Access to a Skilled Medical Interpreter?
Are Translation Services Available?
Handicap accessible lifts?
Handicap accessible scales?
Handicap accessible bathrooms, stalls, grab bar?
Does the office have accommodations for individuals with physical disabilities?

Business Information – New Tax IDs require a Contract and W9. Disclosure of Ownership is required for Medicaid networks.

Payment Information

Payment Type?

Regular Office Hours

Participating Providers

Please provide a list of all providers who will provide patient care at this location. (Attach a separate sheet if needed.)

Signature

I hereby certify that the above information is true and accurate. I understand that the applicable network has complete discretion in accepting or rejecting my application. I also consent to the release of relevant information provided on this form to network’s clients and members for purposes of paying claims and referring members. I authorize Sun Life to obtain all information necessary to process my application.

I agree with the above certification and statements
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PREVENTISTRY PULSE

The newsletter designed for anyone who wants to improve oral health for themselves, their families, customers or communities.