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Premier Dental Group Recred Dentist Profile

Each applying dentist must fully complete and sign a Dentist Profile. 

This form does not save any data you enter. Therefore, please have all necessary information ready before starting this form to ensure a smooth completion process. To avoid losing your progress, do not navigate away from this page or click elsewhere on the site. Doing so will require you to start from the beginning.

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

Provider Information

Licensure

Please list all current and past licenses.

Additional License(s)
Additional License(s)
Additional License(s)

Please attach additional license(s)

Do you have a DEA License Number?

I do not have a DEA license. I refer my patients to their Primary Care Physician or Urgent Care/Emergency Room. Any prescriptions needed for my patients will be written by:

Do you have a CDS Number?

I do not have a CDS License. I refer my patients to their Primary Care Physician or Urgent Care/Emergency Room. Any prescriptions needed for my patients will be written by:

American Board Certification

Are you American Board Certified?
Board Name

Professional Education

Please list post‐graduate education completions dates, unless you are an Allied Health Professional, then provide undergraduate information.

Residency

Please list all training programs with completion dates.

Work History

Please list the last 5 years of work history with MM/YYYY below or attach a copy of your CV. If your graduation or completion of a residency is less than 5 years, please list your work history from graduation or completion of a residency.  Any gaps over 6 months must include an explanation.

Additional Practice
Additional Practice

Attach additional affiliations

Hospital Affiliations

Please list all hospital and/or accredited healthcare facility affiliations (e.g., Free Standing Facility, Ambulatory Care, Urgent Care) with dates in MM/YYYY format, where you hold or have held membership and/or clinical privileges over the last five years.

Additional Affiliation
Additional Affiliation

Attach additional affiliations

Professional Liability Insurance

Please list current professional liability insurance carrier. If covered by a Federal Tort, attach a copy of the Notice of Deeming Action.

Attach a copy of the current Insurance Certificate. 

If your Insurance is expiring within the next 30 days, please include a copy of your current Insurance Certificate and a copy of your new Insurance Certificate.

Questionnaire

All questions must be checked yes or no. For each "Yes" answer, complete a narrative that includes dates, underlying circumstances and disposition.

1. Has your Professional License been limited, suspended, denied, revoked, restricted, subject to probationary conditions, or have proceedings been instituted against you?
2. Have you allowed your Professional License to expire in a state in which you no longer practice? Please list the states:
3. Other than allowing a license to expire because you no longer practice in a state, have you voluntarily relinquished, reduced, restricted, or otherwise limited your Professional License in any jurisdiction?
4. Have you been reprimanded or disciplined by any State or Commonwealth Department of Regulation and Licensure or any Professional Examining Board?
5. Has your participation for receiving payment under the Medical Assistance, Medicaid, or Medicare program been suspended or limited or have you voluntarily terminated your participation?
6. Has your participation with a managed care organization, other health care organization, or hospital privileges been suspended, limited, or terminated?
7. Have you had a judgment made against you for alleged malpractice, negligence, or related matters? Are any cases pending?
8. Have you had any judgments made against you in a professional liability case or has your liability insurer placed any conditions or restrictions on your coverage or ability to attain coverage?
9. Have any litigation settlements been made on your behalf?
10. Are you currently using illegal drugs?
11. Are you, or have you been, under treatment for the use of narcotics, barbiturates, alcohol, or other drugs?
12. Do you presently have any physical or mental conditions that would adversely affect your ability to provide high quality professional services? Are there any accommodations that need to be considered? Please list accommodations.
13. Have you been convicted of any criminal offenses, pending or otherwise, other than a minor traffic violation?
14. Do you use any form of protective stabilization without having completed a residency program, a graduate program, or a Continuing Medical Education (CME) certified course in protective stabilization?

Certification, Statements, and Signature

I hereby acknowledge that the information provided in this application is material to the determination by Sun Life whether or not to execute an agreement with me. I hereby represent and warrant that all information provided herein is true, correct and complete to the best of my knowledge, and I agree to notify Sun Life in the event an error is discovered or when new events occur which alter the validity of any response herein. I hereby authorize Sun Life to consult with individuals or institutions with which I have been associated and with others, including but not limited to past and present malpractice carriers, educational institutions, and state licensing boards, who may have information bearing on my professional competence, character and ethical qualifications and authorize the release of any such written or oral verification as needed by Sun Life. I hereby release from liability for any such entity, institution, or organization that provides information as part of the application process.

I certify that:

  • All parties of material interest have been identified and include no persons or entities with a potential for profit from self-referral,
  • All services are provided by and under the "on Premise" supervision of a licensed provider,
  • The above information is complete, correct and true to the best of my knowledge,
  • My malpractice information is current at the time of application and the limits are at or exceed the minimum amounts required by Sun Life or its Network Users1.

 

Individual Provider Participation Attestation

Attestation to confirm that you have agreed to become a Participating Provider/Provider Dentist in the applicable provider network, by means of your or your office's provider agreement, to render services to Sun Life and Network User members pursuant to the applicable agreement. 

I give permission for each owner, member, and partner for the applicable Tax IDs listed above to act on my behalf when working with Sun Life to arrange dental services. This includes the authority to sign and deliver any necessary contracts or paperwork in my name. I also allow them to take any actions needed to carry out these responsibilities—as if I were doing it myself. They can delegate this authority to someone else if needed, and I agree in advance to anything they lawfully do under this agreement.

I hereby certify that the above information is true and accurate. I understand that Sun Life and Network User 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 agree to be bound by all of the terms and provisions of the applicable provider agreement.

I agree with the above certification and statements

All applications are subject to review and approval by Sun Life.  All applications are subject to review and approval by Sun Life.  Sun Life does not discriminate or base credentialing decisions on race, ethnicity, or language.  Providing such information is not required to submit a complete credentialing application. 

All information contained in a credentialing file will be held in strict confidence and available for review by only duly authorized employees of Sun Life, the Plan, and/or third‐party review organizations (i.e. NCQA, etc.). Practitioner has the right to obtain a copy of their credentialing file by submitting a written, signed request to the Manager of Credentialing at the corporate headquarters for Sun Life. Any corrections, additions, or clarifications to these files must be submitted in writing to the Manager of Credentialing within 30 days of the original submission. This information will be added to the provider application and considered in the credentialing decision. The practitioner has the right, upon request, to be informed of the status of their credentialing or recredentialing application via phone or email. If the Credentials Committee recommends the acceptance of an application with restrictions, denial of an application, or discipline or termination of a practitioner, written notification will be issued within 30 days of that decision. The practitioner then has 30 days from the date of the notice to submit a written appeal of that decision. Appeals should be addressed to the Credentials Committee, sent to Sun Life corporate address. In the event that a dentist’s application for participation is rejected or limited for reasons pertaining to the applicant’s professional conduct or competence, Sun Life is required to submit a report to the Plan. National Practitioner Data Bank and the state licensing board as required by law.

Notice to California residents:

This Privacy Policy and Notice describes the personal information we collect from California residents, how we use it, and your rights. You can read how we protect your personal information at: bit.ly/CA-Privacy. 

Last modified September 9, 2025
Version 1.0