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Dental Benefits Issue Submission Form

Member Dentist Information

What dental information do you have? *This question is required.

ADA Number *This question is required.

License Number *This question is required.

License State *This question is required.

License Type *This question is required.

Best Contact

First Name *This question is required.

Last Name *This question is required.

Email *This question is required. This question requires a valid email address.

Phone *This question is required.

Preferred Method of Contact *This question is required.

Role in dental practice *This question is required.

Does the issue and/or question pertain to a dental benefit plan? *This question is required.

Please select the plan from the list *This question is required.

If Other, please specify plan *This question is required.

Are you contracted with the plan as a participating provider? *This question is required.

Does the issue and/or question pertain to a claim? *This question is required.

Please select a topic describing your dental benefit issue and/or question *This question is required.

Please enter the details *This question is required.

If you filed a complaint with the dental plan’s regulator (the Department of Managed Health Care, Department of Insurance, or the US Department of Labor), provide the date of the filing. This question requires a valid date format of MM/DD/YYYY.

calendar

How did you learn about CDA’s dental benefits submission form?

Please enter the name of the source *This question is required.

HIPAA Business Associate Agreement