Dental Credentialing Form PDF Details

Dental credentialing is the process of verifying the qualifications of dental professionals. This process is important to ensure that patients receive quality care. The American Dental Association (ADA) oversees the credentialing process by accrediting dental schools and programs, as well as establishing standards for dental professionals. To be accredited, a school or program must meet rigorous quality and safety requirements. The ADA also maintains a database of accredited dentists, which helps patients find qualified providers in their area. Patients can be confident that by choosing an accredited dentist, they are receiving care from a highly-qualified professional.

Question	Answer
Form Name	Dental Credentialing Form
Form Length	26 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	6 min 30 sec
Other names	dental credentialing form, metlife dental credentialing application, maryland uniform dental credentialing form, metlife credentialing application

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INSURANCE

ADMINISTRATION

Maryland Uniform Dental Credentialing Form

Instructions

This form may be completed and sent electronically or in printed form.

Read all instructions

Tips to avoid processing delays

1. Complete only this application and its supplemental forms. Do not use another application or credentialing form.

carefully prior to

2. Use a blue or black ink ball-point pen only. Do not use a pencil or a felt-tip pen.

submitting your

3. Enter information legibly and inside the boxes and spaces provided.

application.

4. Complete all sections that are applicable to you. Use supplemental forms where appropriate.

5. Some fields use ÒcodesÓ to help you easily report information (e.g., schools, languages). Code lists are found on pages 24-26.

6. Fields with asterisks (*) indicate that a response is required. All other fields will be considered not applicable if left blank.

SECTION 1

Personal Information and Professional IDs

Provider Type

Code list is found on page 24. Enter the

associated 3-digit code in the space

YES

NO DO YOU PRACTICE EXCLUSIVELY WITHIN THE INPATIENT SETTING?*

provided.*

Name

Do not use nicknames

or initials, unless they

LAST NAME*

SUFFIX (JR, III)

are part of your legal

name.

FIRST NAME*

MIDDLE NAME

HAVE YOU EVER USED ANOTHER NAME?*

YES

IF YES, PLEASE LIST ALL OTHER NAMES USED AND THEIR DATES OF USE BELOW.

OTHER LAST NAME

SUFFIX (JR, III)

OTHER FIRST NAME

OTHER MIDDLE NAME

DATE STARTED USING OTHER NAME (MM/DD/YYYY)

DATE STOPPED USING OTHER NAME (MM/DD/YYYY)

General

Information

GENDER*

MALE

FEMALE

DATE OF BIRTH*

(MM/DD/YYYY)

Only enter a Foreign

National Identification

Number if you do not

have a SSN. Do not

enter National Provider

CITY OF BIRTH

STATE OF

COUNTRY OF

Identification (NPI)

BIRTH

Number here.

SSN*

Code lists are found on

FOREIGN NATIONAL IDENTIFICATION NUMBER (FNIN)

FNIN COUNTRY OF ISSUE

pages 25-27. Enter the

associated 3-digit code

in the space provided.

ENTER ALL NON-ENGLISH

LANGUAGES YOU SPEAK

LANGUAGE CODE

Home Address

NUMBER

STREET

APT NUMBER

CITY

STATE

ZIP CODE

TELEPHONE

NOTE: This

information used for

E-MAIL

application follow-up.

FAX

PREFERRED METHOD OF CONTACT*		E-MAIL

FAX

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.	PAGE 01
	UDCF 1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 1

Personal Information and Professional IDs (Continued)

Professional

IDs

FEDERAL DEA NUMBER

DEA ISSUE DATE (MM/DD/YYYY)

Include all state

licenses, DEA

Registration and State

Controlled Dangerous

DEA STATE OF REGISTRATION

DEA EXPIRATION DATE (MM/DD/YYYY)

Substance (CDS)

certification numbers.

Provide all current and

CDS CERTIFICATE NUMBER

CDS ISSUE DATE (MM/DD/YYYY)

previous licenses/

certifications.

CDS STATE OF REGISTRATION

CDS EXPIRATION DATE (MM/DD/YYYY)

Non-licensed

professionals should

enter certification/

registration number in

STATE LICENSE NUMBER

LICENSE ISSUING STATE

LICENSE ISSUE DATE (MM/DD/YYYY)

the space provided for

IF THIS IS A STATE LICENSE, ARE YOU

license number.

YES

CURRENTLY PRACTICING IN THIS STATE?

LICENSE EXPIRATION DATE (MM/DD/YYYY)

Provider Type Code List is

found on Page 24.

PROVIDER TYPE CODE

STATE LICENSE NUMBER

LICENSE ISSUING STATE

LICENSE ISSUE DATE (MM/DD/YYYY)

IF THIS IS A STATE LICENSE, ARE YOU

YES

CURRENTLY PRACTICING IN THIS STATE?

LICENSE EXPIRATION DATE (MM/DD/YYYY)

Provider Type Code List is

found on Page 24.

PROVIDER TYPE CODE

Other ID

ARE YOU A PART-

ICIPATING MEDICAID

YES

Numbers

PROVIDER?*

MEDICAID NUMBER

MEDICAID STATE

Indicate all that apply.

NATIONAL PROVIDER IDENTIFICATION (NPI) NUMBER

USMLE NUMBER (WITHOUT HYPHENS)

WORKERS COMPENSATION NUMBER

ECFMG NUMBER (NON-U.S./CANADIAN GRADUATE ONLY)

ECFMG CERTIFICATE ISSUE DATE (NON-U.S./CANADIAN GRADUATE ONLY)

(MM/DD/YYYY)

License

GENERAL DENTAL

YES

LIMITED DENTAL

YES

Status

LICENSE

Indicate all that apply.

TEMPORARY

YES

INACTIVE DENTAL

YES

DENTAL LICENSE

LICENSE

Status Code List is found

TEACHER’S DENTAL

YES

OTHER LICENSE

LICENSE

STATUS

on Page 24.

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 02

UDCF 1.1.08

Section 2

Education and Training

Undergraduate

UNDERGRADUATE SCHOOL

School

Provide the appropriate

information for the

OFFICIALNAME OF UNDERGRADUATE SCHOOL

school that issued your

undergraduate degree.

ADDRESS

CITY

STATE

ZIP/POSTALCODE

COUNTRYCODE

TELEPHONE

FAX

DID YOU COMPLETE YOUR

YES

UNDERGRADUATE EDUCATION

ATTHIS SCHOOL?

START DATE (MM/YYYY)

END DATE (GRADUATION DATE)

DEGREE AWARDED

(MM/YYYY)

Professional

GRADUATE TYPE*:

School(s)

U.S. OR CANADIAN GRADUATE

NON-U.S./CANADIAN GRADUATE

FIFTH PATHWAYGRADUATE

Provide the appropriate

information for the

school that issued your

U.S. OR CANADIAN SCHOOL

professional degree.

Code lists are found on

SCHOOLCODE (U.S./

NAME OF U.S./

CANADIAN ONLY)

CANADIAN SCHOOL:

pages 24-26. Enter the

associated 3-digit code

DID YOU COMPLETE YOUR

in the space provided.

GRADUATE EDUCATION AT THIS

YES

SCHOOL?

START DATE* (MM/YYYY)

END DATE (GRADUATION DATE)*

DEGREE AWARDED

(MM/YYYY)

NON - U.S. OR CANADIAN SCHOOL

OFFICIALNAME OF NON-U.S. PROFESSIONALSCHOOL

ADDRESS

CITY

COUNTRYCODE

POSTALCODE

DID YOU COMPLETE YOUR

YES

GRADUATE EDUCATION AT THIS

SCHOOL?

START DATE* (MM/YYYY)

END DATE (GRADUATION DATE)*

DEGREE AWARDED

(MM/YYYY)

OTHER PROFESSIONALSCHOOL

OFFICIALNAME OF OTHER PROFESSIONALSCHOOL

CITY		COUNTRYCODE


START DATE* (MM/YYYY)	END DATE (GRADUATION DATE)*		DEGREE AWARDED
	(MM/YYYY)

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

PAGE 03

UDCF1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 2

Education and Training (Continued)

Training

List all training

SCHOOL CODE (E.G.,

programs you

AFFILIATED MEDICAL

attended. Use one

SCHOOL)

section per institution.

INSTITUTION/HOSPITAL NAME (USE BOTH LINES IF REQUIRED)

Professional School

Code lists are found on

pages 24-26. Enter the

NUMBER

STREET

SUITE/BUILDING

associated 3-digit code

in the space provided.

CITY

STATE

ZIP/POSTAL CODE

COUNTRY CODE

TELEPHONE

FAX

DID YOU COMPLETE THIS TRAINING PROGRAM AT THIS

YES

INSTITUTION?

(IF NOT, PLEASE USE THE SPACE BELOW TO EXPLAIN.)

List each

INTERNSHIP/

FELLOWSHIP

OTHER

RESIDENCY

department

separately, if

START DATE (MM/YYYY))

END DATE (MM/YYYY)

applicable.

List

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

Internship/

Residency,

Fellowship

and Other

NAME OF DIRECTOR

programs

separately.

INTERNSHIP/

FELLOWSHIP

OTHER

RESIDENCY

START DATE (MM/YYYY)

END DATE (MM/YYYY)

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

NAME OF DIRECTOR


INTERNSHIP/
INTERNSHIP/	FELLOWSHIP	OTHER
RESIDENCY	FELLOWSHIP	OTHER
RESIDENCY

START DATE (MM/YYYY))	END DATE (MM/YYYY))

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

NAME OF DIRECTOR

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 04

UDCF 1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

Section 3

Professional / Dental Specialty Information

Specialty

GENERALDENTIST

YES

Status

SPECIALIST

YES

PRIMARY

SPECIALTY

Primary

SPECIALTY

INITIAL

DOYOU WISH TO

Specialty

CODE

CERTIFICATION DATE

BE LISTED IN

HMO

YES

(MM/DD/YYYY)

THE DIRECTORY

UNDER THIS

CERTIFIED?BOARD

RECERTIFICATION

SPECIALTY?

Code lists are found on

YES

DATE (IF APPLICABLE)

PPO

YES

pages 24-26. Enter the

(MM/DD/YYYY)

associated 3-digit code

CERTIFYING

EXPIRATION DATE

in the space provided.

BOARD

(IF APPLICABLE)

POS

YES

CODE

(MM/DD/YYYY)

IFNOT

IHAVE TAKEN

IINTEND TO SIT FOR AN

IDO NOT INTEND TO TAKE

BOARD

EXAM, RESULTS

EXAM ON (MM/DD/YYYY)

ACERTIFYING BOARD EXAM.

CERTIFIED

PENDING FOR

(SELECT

ONE)

CERTIFYING BOARD CODE

IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE ACERTIFYING BOARD EXAM, PLEASE USE THE

FOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.

Secondary

SPECIALTY

INITIAL

DO YOU WISH TO

CERTIFICATION DATE

BELISTED IN

HMO

YES

CODE

Specialty

(MM/DD/YYYY)

THE DIRECTORY

UNDER THIS

BOARD

RECERTIFICATION

SPECIALTY?

Code lists are found on

YES

DATE (IF APPLICABLE)

PPO

YES

CERTIFIED?

(MM/DD/YYYY)

pages 24-26. Enter the

associated 3-digit code

CERTIFYING

EXPIRATION DATE

in the space provided.

BOARD

(IF APPLICABLE)

POS

YES

CODE

(MM/DD/YYYY)

IF NOT

IHAVE TAKEN

IINTEND TO SIT FOR AN

IDO NOT INTEND TOTAKE

BOARD

EXAM, RESULTS

EXAM ON (MM/DD/YYYY)

ACERTIFYING BOARD EXAM.

CERTIFIED

PENDING FOR

(SELECT

ONE)

CERTIFYING BOARD CODE

IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE ACERTIFYING BOARD EXAM, PLEASE USE THE

FOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.

Primary

Credentialing

Contact

LAST NAME

CHECK HERE TO

USE THE OFFICE

FIRST NAME

M.I.

MANAGER AND

ADDRESS OF THE

PRIMARYPRACTICE

LOCATION ON

PAGE 7 AS THE

NUMBER

STREET

SUITE/BUILDING

CREDENTIALING

INFORMATION.

CITY

STATE

ZIPCODE

TELEPHONE

FAX

E-MAILADDRESS (Even if you checked the boxes above, please provide the e-mail address, if available.)

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

PAGE 05

UDCF1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information

Primary

NOTE: IF YOU INDICATED THAT YOU PRACTICE EXCLUSIVELY WITHIN THE INPATIENT SETTING ON PAGE 1, YOU ARE ONLY REQUIRED TO COMPLETE THE

PRIMARY CREDENTIALING CONTACT QUESTION ON PAGE 5. SECTION 4 MAY BE LEFT BLANK AND YOU MAY PROCEED TO SECTION 5 ON PAGE 11.

Practice

CURRENTLY

PREVIOUS OR FUTURE

Location

PRACTICING AT

YES

START DATE?

If you have additional

THIS ADDRESS?*

(MM/DD/YYYY)

practice locations, use

the Supplemental

DENTAL GROUP / PRACTICE NAME TO APPEAR IN DIRECTORY (DO NOT ABBREVIATE)*

Practice Location

Information Form on

pages 19-20.

GROUP / CORPORATE NAME AS IT APPEARS ON W-9, IF DIFFERENT FROM ABOVE (DO NOT ABBREVIATE)

NOTE: ÒGeneral

CorrespondenceÓ refers

NUMBER*

STREET*

SUITE/BUILDING

to any correspondence

that might be sent to the

provider that does not

solely relate to creden-

CITY*

STATE*

ZIP CODE*

tialing or billing

SEND GENERAL

information.

YES

CORRESPON-

DENCE HERE?*

TIP Your Individual Tax

TELEPHONE*

FAX

ID is assumed to be

your Primary Tax ID

unless you specify

OFFICE E-MAILADDRESS

otherwise to the right.

PRIMARY

USE INDIVIDUAL

USE GROUP

TAX ID

(ONE ONLY)*

INDIVIDUAL TAX ID

GROUP TAX ID

Office Manager

or Business

Office Staff

LAST NAME*

Contact

List office staff and

FIRST NAME*

M.I.

billing contacts

separately. You may

use the check boxes

below for convenience.

TELEPHONE*

FAX

Do not write

instructions like Òsee

aboveÓ. These

responses will be

E-MAILADDRESS

rejected and will

require follow-up.

Billing Contact

LAST NAME*

CHECK HERE TO

USE OFFICE

MANAGER AND

OFFICE ADDRESS

FIRST NAME*

M.I.

AS BILLING

INFORMATION

NUMBER*

STREET*

SUITE/BUILDING

NOTE:

Even if you checked

CITY*

STATE*

ZIP CODE*

the box above, please

provide the

E-mail Address of the

TELEPHONE*

FAX

Billing Contact.

E-MAILADDRESS

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 06

UDCF 1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information (Continued)

Payment and

ELECTRONIC

YES

Remittance

BILLING

CAPABILITIES?*

BILLING DEPARTMENT (IF HOSPITAL-BASED)

YOUR “CHECK PAYABLE TO”

INFORMATION SHOULD BE

CONSISTENT WITH YOUR

W-9.

CHECK PAYABLE TO*

CHECK HERE TO

USE OFFICE

MANAGER AND

OFFICE ADDRESS

LAST NAME*

AS PAYEE

INFORMATION

FIRST NAME*

M.I.

NUMBER*

STREET*

SUITE/BUILDING

NOTE:

Even if you checked

CITY*

STATE*

ZIP CODE*

the box above, please

provide the

E-mail Address of the

TELEPHONE*

FAX

Payee Contact.

E-MAILADDRESS

Office Hours

(USE HHMM FORMATAND ROUND TO THE NEAREST HALF-HOUR)

START

A=AM

END

A=AM

START

A=AM

END

A=AM

P=PM

MONDAY

FRIDAY

TUESDAY

SATURDAY

WEDNESDAY

SUNDAY

THURSDAY

24/7 PHONE COVERAGE?*

IF YES

ANSWERING

VOICE MAIL WITH

VOICE MAIL

COVERING

YES

INSTRUCTIONS TO CALL

WITH OTHER

OTHER

SERVICE

COLLEAGUE

ANSWERING SERVICE

INSTRUCTIONS

CURRENT WAIT TIME FOR

NUMBER OF OPERATORIES

INITIALAPPOINTMENT

AVAILABLE

Open Practice

ACCEPT NEW PATIENTS INTO THIS PRACTICE?*

YES

ACCEPT ALL NEW PATIENTS?*

YES

Status

ACCEPT EXISTING PATIENTS WITH CHANGE OF PAYOR?*

YES

ACCEPT NEW MEDICAID PATIENTS?*

YES

ACCEPT NEW PATIENTS WITH PROVIDER REFERRAL?*

YES

IF ANY OF THE

ABOVE INFORMATION

VARIES BY PLAN,

EXPLAIN

ARE THERE ANY

PRACTICE LIMITATIONS?*

YES

IF YES,

EXPLAIN

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 07

UDCF 1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

SECTION 4

PRACTICE LOCATION INFORMATION (Continued)

MID-LEVEL

DOMID-LEVELPRACTITIONERS CARE FOR PATIENTS IN YOUR

YES

PRACTICE?*

PRACTITIONERS

(IF YES, PLEASE PROVIDE THE INFORMATION BELOW)

Identify the primary

mid-level practitioners

ofyour practice.

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE

(E.G., ADHA, RDH, CDA, RDA, CDT)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE

(E.G., ADHA, RDH, CDA, RDA, CDT)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE

(E.G., ADHA, RDH, CDA, RDA, CDT)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

PAGE 08

UDCF1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information (Continued)

Languages

LANGUAGES

NON-ENGLISH LANGUAGES

Code lists are found on

SPOKEN BYOFFICE PERSONNEL

pages 24-25. Enter the

LANGUAGE CODE

associated 3-digit code

INTERPRETERS

LANGUAGES

in the space provided.

YES

AVAILABLE?*

INTERPRETED

LANGUAGE CODE

Accessibilities

YES

DOES THIS OFFICE MEET ADAACCESSIBILITYREQUIREMENTS?*

DOES THIS SITE OFFER HANDICAPPED

DOES THIS SITE OFFER OTHER

YES

ACCESSIBLE BY

YES

ACCESS FOR THE FOLLOWING

SERVICES FOR THE DISABLED?*

PUBLIC TRANSPORTATION?*

YES

BUILDING?*

TEXT TELEPHONY(TTY)*

YES

AMERICAN SIGN LANGUAGE*

PARKING?*

YES

RESTROOM?*

YES

MENTAL/PHYSICALIMPAIRMENT

YES

SERVICES*

TDDY/HEARING IMPAIRED

YES

OTHER HANDICAPPED ACCESS

OTHER TRANSPORTATION ACCESS

Certifications

DO YOU HOLD THE FOLLOWING CERTIFICATIONS? IF YES, PROVIDE EXPIRATION DATES.

BASIC LIFE

YES

EXPIRATION DATE

SUPPORT

(MM/DD/YYYY)

CPR

YES

EXPIRATION DATE

(MM/DD/YYYY)

Services

DOES THIS LOCATION PROVIDEANYOF THE FOLLOWING SERVICES?

RADIOLOGY

YES

IFYES, TYPES OF X-RAY

INTRAORAL

YES

PANOGRAPHIC

YES

X-RAYUNIT

SERVICES?

EQUIPMENT

X-RAYUNIT

ANESTHESIA

IF YES, WHAT

CONSCIOUS

YES

NITROUS

YES

CLASS/CATEGORY

SEDATION?

OXIDE?

SERVICES?

DO YOU USE?

IF YES, WHO

ADMINISTERS IT?

LAST NAME

FIRST NAME

STERILIZATION

YES

CHEMCLAVE

YES

METHODS USED

AUTOCLAVE

OTHER

YES

EXPLAIN

TYPE OF PRACTICE

SOLO PRACTICE

SINGLE SPECIALTYGROUP

MULTI-SPECIALTYGROUP

(SELECT ONE ONLY)*

CORPORATION

LLC

OTHER

EXPLAIN

ADDITIONALOFFICE PROCEDURES PROVIDED (INCLUDING SURGICALPROCEDURES)

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

PAGE 09

UDCF1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information (Continued)

Partners/

LIST ALLPARTNERS/ASSOCIATES AT THIS PRACTICE

Associates

Code lists are found on

LAST NAME

SPECIALTYCODE

COVERING

pages 24-26. Enter the

COLLEAGUE

associated 3-digit code

(Y/N)?

inthe space provided.

FIRST NAME

M.I.

PROVIDER TYPE (CODE PG 24)

STATE LICENSE NUMBER

LICENSE ISSUING STATE

LICENSE ISSUE DATE (DD/MM/YYYY)

LAST NAME

SPECIALTYCODE

COVERING

COLLEAGUE

(Y/N)?

FIRST NAME

M.I.

PROVIDER TYPE (CODE PG 24)

STATE LICENSE NUMBER

LICENSE ISSUING STATE

LICENSE ISSUE DATE (DD/MM/YYYY)

LAST NAME

SPECIALTYCODE

COVERING

COLLEAGUE

(Y/N)?

FIRST NAME

M.I.

PROVIDER TYPE (CODE PG 24)

STATE LICENSE NUMBER

LICENSE ISSUING STATE

LICENSE ISSUE DATE (DD/MM/YYYY)

DOYOU HAVE MORE THAN THREE

YES

IF MORE THAN THREE,

PARTNERS/ASSOCIATES AT THIS PRACTICE?

HOW MANY?

Covering

LIST PRIMARYCOVERING COLLEAGUES THAT ARE NOTPARTNERS/ASSOCIATES AT THIS PRACTICE

Colleagues

Code lists are found on

LAST NAME

SPECIALTYCODE

pages 24-26. Enter the

associated 3-digit code

in the space provided.

FIRST NAME

M.I.

PROVIDER TYPE (CODE PG 24)

LAST NAME

SPECIALTYCODE

FIRST NAME

M.I.

PROVIDER TYPE (CODE PG 24)

DO YOU HAVE MORE THAN TWO COVERING

YES

IF MORE THAN TWO,

COLLEAGUES AT THIS PRACTICE?

HOW MANY?

Section 5

Hospital Affiliations

Admitting

DO YOU HAVE

YES

DO YOU HAVE HOSPITAL

YES

Arrangements

HOSPITAL

PRIVILEGES AT MORE

PRIVILEGES?*

THAN ONE HOSPITAL?

IF YOU DO NOT ADMIT PATIENTS, WHAT TYPE OF ADMITTING ARRANGEMENTS DO YOU HAVE?

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

PAGE 10

UDCF1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 5

Hospital Affiliations (Continued)

Hospital

PRIMARY HOSPITAL

Privileges

If applicable, list

HOSPITAL NAME

primary hospital

affiliation then

secondary or other

NUMBER

STREET

SUITE/BUILDING

current affiliation.

CITY

STATE

ZIP CODE

TELEPHONE

FAX

DEPARTMENT NAME

DEPARTMENT DIRECTOR’S LAST NAME

DEPARTMENT DIRECTOR’S FIRST NAME

M.I.

FULL, UNRESTRICTED

YES

ARE PRIVILEGES

YES

PRIVILEGES?

TEMPORARY?

AFFILIATION START DATE (MM/YYYY)

AFFILIATION END DATE (MM/YYYY)

OF YOUR TOTALANNUAL

ADMISSIONS, WHAT PERCENTAGE

IS TO THIS HOSPITAL?

ADMITTING PRIVILEGE STATUS (E.G. NONE, FULL UNRESTRICTED, PROVISIONAL, TEMPORARY)

OTHER HOSPITAL

HOSPITAL NAME

NUMBER

STREET

SUITE/BUILDING

CITY

STATE

ZIP CODE

TELEPHONE

FAX

DEPARTMENT NAME

DEPARTMENT DIRECTOR’S LAST NAME

DEPARTMENT DIRECTOR’S FIRST NAME

M.I.

FULL, UNRESTRICTED

YES

ARE PRIVILEGES

YES

PRIVILEGES?

TEMPORARY?

AFFILIATION START DATE (MM/YYYY)

AFFILIATION END DATE (MM/YYYY)

OF YOUR TOTALANNUAL

ADMISSIONS, WHAT PERCENTAGE

IS TO THIS HOSPITAL?

ADMITTING PRIVILEGE STATUS (E.G. NONE, FULL UNRESTRICTED, PROVISIONAL, TEMPORARY)

PLEASE EXPLAIN

TERMINATED AFFILIATION

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 11

UDCF 1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

Section 6

Professional Liability Insurance Carrier

Professional

SELF-INSURED?*

YES

Liability

Insurance

CARRIER OR SELF-INSURED NAME*

Carrier

IMPORTANT

NUMBER*

STREET*

SUITE/BUILDING

IFYOU DO NOT

CARRY

MALPRACTICE

INSURANCE, CHECK

CITY*

STATE*

ZIPCODE*

THIS BOXAND SKIP

THIS SECTION.

TYPE OF

INDIVIDUAL

SHARED

COVERAGE?*

ORIGINALEFFECTIVE DATE*

EFFECTIVE DATE*

EXPIRATION DATE

DO YOU HAVE UNLIMITED COVERAGE

YES

WITH THIS INSURANCE CARRIER?*

AMOUNT OF COVERAGE PER OCCURRENCE

AMOUNT OF COVERAGE AGGREGATE

POLICYINCLUDES TAILCOVERAGE?

YES

POLICYNUMBER*

Professional

SELF-INSURED?

YES

Liability

CARRIER OR SELF-INSURED NAME

Insurance

Carrier

List other current,

NUMBER*

STREET*

SUITE/BUILDING

future, or previous

carrier(s) if current

carrier is less than ten

(10) years.

CITY*

STATE*

ZIPCODE*

NOTE:Alonger period

TYPE OF

INDIVIDUAL

SHARED

COVERAGE?*

may be required by

your healthcare entity.

ORIGINALEFFECTIVE DATE*

EFFECTIVE DATE* (MM/YYYY)

EXPIRATION DATE (MM/YYYY)

(MM/DD/YYYY)

If you have additional

DO YOU HAVE UNLIMITED COVERAGE

YES

Insurance, use the

WITH THIS INSURANCE CARRIER?

AMOUNT OF COVERAGE PER OCCURRENCE

AMOUNT OF COVERAGE AGGREGATE

Supplemental

Insurance Form on

POLICYINCLUDES TAILCOVERAGE?

YES

page 21.

POLICYNUMBER*

Section 7

Work History and References

Military

Are you currently on active military

YES

Duty

duty or military reserve?*

Work History

WORK HISTORY

Include a chronological

work history for the

past 10 years,

PRACTICE / EMPLOYER NAME

excluding current

positions listed in

section 4.

NUMBER

STREET

SUITE/BUILDING

Alonger period may be

required by your dental

plan organization.

CITY

STATE

ZIP/POSTALCODE

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

PAGE 12

UDCF1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

Section 7

Work History and References (Continued)

Work History

Do not list current

positions. Those

TELEPHONE

FAX

should be listed in

Section 4.

Include a chronological

COUNTRYCODE

START DATE (MM/YYYY)

END DATE (MM/YYYY)

work history for the

past10 years.

REASON FOR DEPARTURE (IF APPLICABLE)

Alonger period may be

required by your dental

plan organization.

WORK HISTORY

PRACTICE / EMPLOYER NAME

NUMBER

STREET

SUITE/BUILDING

CITY

STATE

ZIP/POSTALCODE

TELEPHONE

FAX

COUNTRYCODE

START DATE (MM/YYYY)

END DATE (MM/YYYY)

REASON FOR DEPARTURE (IF APPLICABLE)

WORK HISTORY

PRACTICE / EMPLOYER NAME

NUMBER

STREET

SUITE/BUILDING

CITY

STATE

ZIP/POSTALCODE

TELEPHONE

FAX

COUNTRYCODE

START DATE (MM/YYYY)

END DATE (MM/YYYY)

REASON FOR DEPARTURE (IF APPLICABLE)

*REQUIRED RESPONSE. NO RESPONSE MAYCAUSE PROCESSING DELAYSAND REQUIRE FOLLOW-UP.

PAGE 13

UDCF1.1.08

	* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
Section 7		Work History and References (Continued)
Gaps in		PLEASE EXPLAIN ANY TIME PERIODS OR GAPS IN TRAINING OR WORK HISTORY THAT HAVE OCCURRED SINCE GRADUATION FROM PROFESSIONAL SCHOOLAND ARE
Gaps in		LONGER THAN THREE MONTHS IN DURATION OR OF A SHORTER DURATION IF REQUIRED BY THE ORGANIZATION FOR WHICH YOU ARE BEING CREDENTIALED.

Professional /
Work History
Work History		GAP START DATE	GAP END DATE
		(MM/YYYY)	(MM/YYYY)

GAP START DATE (MM/YYYY)

GAP END DATE (MM/YYYY)

GAP START DATE (MM/YYYY)

GAP END DATE (MM/YYYY)

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 14

UDCF 1.1.08

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 7

Work History and References (Continued)

Professional

References

LAST NAME*

Provide three

professional references

to whom you are not

related or are not

FIRST NAME*

PROVIDER TYPE (CODE PG 24)

partners in your

practice.

Code lists are found on

NUMBER*

STREET*

APT/SUITE/BUILDING

pages 24-26. Enter the

associated 3-digit code

for provider type.

CITY*

STATE*

ZIP CODE*

NOTE:

You are required to

TELEPHONE

FAX

provide exactly 3

references. Your

application will not be

complete without this

LAST NAME*

information.

Please check with

FIRST NAME*

PROVIDER TYPE (CODE PG 24)

credentialing entity for

any special

requirements.

NUMBER*

STREET*

APT/SUITE/BUILDING

CITY*

STATE*

ZIP CODE*

TELEPHONE

FAX

LAST NAME*

FIRST NAME*

PROVIDER TYPE (CODE PG 24)

NUMBER*

STREET*

APT/SUITE/BUILDING

CITY*

STATE*

ZIP CODE*

TELEPHONE

FAX

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 15

UDCF 1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 8	Disclosure Questions
Disclosure
Questions	1.	YES	NO	Has your license, registration or certification to practice in your profession, ever been voluntarily or involuntarily relinquished,
Questions
Answer all questions.				denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any con-
				ditions or limitations by any state or professional licensing, registration or certification board?*

For any ÒYesÓ
response, provide an	2.	YES	NO Has there been any challenge to your licensure, registration or certification?*
explanation on the	2.	YES
explanation on the
Supplemental				Have your clinical privileges or medical staff membership at any hospital or healthcare institution, voluntarily or involuntarily, ever
Disclosure Question
Explanation Form on	3.	YES	NO	been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for
page 22.				reasons other than non-completion of medical record when quality of care was not adversely affected) or have proceedings
				toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee,
				or governing board?*
	4.		NO Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?*
	4.	YES
	5.	YES	NO	Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action,


				by any managed care organizations including HMOs, dental plans, or provider organizations?*
	6.			Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, resi-

		YES	NO	dency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been
				placed on probation, disciplined, formally reprimanded, suspended or asked to resign?*

				Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status
	7.	YES	NO
				as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?*
	8.	YES	NO Have any of your board certifications or eligibility ever been revoked, suspended or voluntarily surrendered?*
	8.	YES
	9.		NO Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?*

		YES
	10.	YES	NO	Do you, or your business entity, own, have an investment in, manage, own stock in, participate in a joint venture, or act as a


				partner, contract consultant or medical/dental advisor in any medical/dental enterprise or medical/dental supplier outside of your
				direct practice where you would financially benefit directly or indirectly?*

	11.			Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or other-

		YES	NO wise restricted in regard to participation in the Medicaid program, or in regard to other federal or state governmental healthcare
				plans or programs?*
				plans or programs?*
				Are you currently the subject of an investigation by any hospital, licensing authority, education or training program, Medicaid
	12.	YES	NO	program, or any other private, federal or state health program or a defendant in any civil action that is reasonably related to

				your qualifications, competence, functions, or duties as a medical professional for alleged fraud, an act of violence, child
				abuse or a sexual offense or sexual misconduct?*
				abuse or a sexual offense or sexual misconduct?*
	13.			To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare
	13.	YES	NO
				Integrity and Protection Data Bank?*
	14.		NO Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies?*
	14.	YES
	15.			Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted, disciplined or


		YES	NO resigned in exchange for no investigation or adverse action within the last ten years for sexual harassment or other illegal
				misconduct?*
				misconduct?*
	16.	YES	NO	Are you currently being investigated or have you ever been sanctioned, reprimanded, or cautioned by a military hospital, facility,

				or agency, or voluntarily terminated or resigned while under investigation or in exchange for no investigation by a hospital or
				healthcare facility of any military agency?*
				healthcare facility of any military agency?*
	17.			Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your
	17.	YES	NO
				individual liability history?*
	18.			Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional liability insurance
	18.	YES	NO
				carrier, based on your individual liability history?*

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 16

UDCF 1.1.08

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 8	Disclosure Questions (Continued)
Disclosure	19.	YES		NO	Have you had any professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past 10 years?*
Disclosure
Questions					If yes, provide information for each case.
Answer all questions.	20.				Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony?*
Answer all questions.
For any ÒYesÓ		YES		NO
response, provide an
response, provide an
explanation on the					In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor
Supplemental	21.	YES		NO
Supplemental
Disclosure Question					traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, compe-
Explanation Form on					tence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offense or sexual
Explanation Form on
page 22.					misconduct?*
IMPORTANT	22.	YES		NO Have you ever been court-martialed for actions related to your duties as a medical professional?*
	22.	YES

If you answered ÒYesÓ			Note: Acriminal record will not necessarily be a bar to acceptance. Decisions will be made by each health plan or
to question #19, you
to question #19, you			credentialing organization based upon all the relevant circumstances, including the nature of the crime.
must complete the
must complete the
Supplemental
Malpractice Claims	23.	YES		NO	Are you currently engaged in the illegal use of drugs?*
Explanation Form on	23.	YES		NO	("Currently" means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on
page 23 for each					one's ability to practice dentistry. It is not limited to the day of, or within a matter of days or weeks before the date of applica-
page 23 for each
malpractice claim.					tion, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of
					drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. ¤ 812.22.
					It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses author-
					ized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of
					prescription controlled substances.)
	24.	YES		NO	Do you use any chemical substances that would in any way impair or limit your ability to practice dentistry and perform the func-
	24.	YES		NO
					tions of your job with reasonable skill and safety?*
	25.	YES		NO Do you have any reason to believe that you would pose a risk to the safety or well being of your patients?*
	25.	YES
	26.	YES		NO	Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonable


					accommodation?*

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 17

UDCF 1.1.08

Standard Authorization, Attestation and Release

(Not for Use for Employment Purposes)

I understand and agree that, as part of the credentialing application process for participation, membership and/or clinical privileges (hereinafter, referred to as "Participation") at or with each healthcare organization indicated on the "List of Authorized Organizations" that accompanies this Provider Application (hereinafter, each healthcare organization on the "List of Authorized Organizations" is individually referred to as the "Entity"), and any of the Entity's affiliated entities, I am required to provide sufficient and accurate information for a proper evaluation of my current licensure, relevant training and/or experience, clinical competence, health status, character, ethics, and any other criteria used by the Entity for determining initial and ongoing eligibility for Participation. Each Entity and its representatives, employ- ees, and agent(s) acknowledge that the information obtained relating to the application process will be held confidential to the extent permitted by law.

I acknowledge that each Entity has its own criteria for acceptance, and I may be accepted or rejected by each independently. I further acknowledge and understand that my cooperation in obtaining information and my consent to the release of information do not guarantee that any Entity will grant me clinical privileges or contract with me as a provider of services. I understand that my application for Participation with the Entity is not an application for employment with the Entity and that acceptance of my application by the Entity will not result in my employment by the Entity.

Authorization of Investigation Concerning Application for Participation. I authorize the following individuals including, without limitation, the Entity, its representa- tives, employees, and/or designated agent(s); the Entity's affiliated entities and their representatives, employees, and/or designated agents; and the Entity's designat- ed professional credentials verification organization (collectively referred to as "Agents"), to investigate information, which includes both oral and written statements, records, and documents, concerning my application for Participation. I agree to allow the Entity and/or its Agent(s) to inspect and copy all records and documents relating to such an investigation.

Authorization of Third-Party Sources to Release Information Concerning Application for Participation. I authorize any third party, including, but not limited to, individuals, agencies, dental groups responsible for credentials verification, corporations, companies, employers, former employers, hospitals, dental or health plans, health maintenance organizations, managed care organizations, law enforcement or licensing agencies, insurance companies, educational and other institutions, mili- tary services, credentialing and accreditation agencies, professional dental societies, state dental boards, the National Practitioner Data Bank, and the Health Care Integrity and Protection Data Bank, to release to the Entity and/or its Agent(s), information, including otherwise privileged or confidential information, concerning my professional qualifications, credentials, clinical competence, quality assurance and utilization data, character, mental condition, physical condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing on my qualifications for Participation in, or with, the Entity. I authorize my current and past professional liability carrier(s) to release my history of claims that have been made and/or are currently pending against me. I specifi- cally waive written notice from any entities and individuals who provide information based upon this Authorization, Attestation and Release.

Authorization of Release and Exchange of Disciplinary Information. I hereby further authorize any third party at which I currently have Participation or had Participation and/or each third party's agents to release "Disciplinary Information," as defined below, to the Entity and/or its Agent(s). I hereby further authorize the Agent(s) to release Disciplinary Information about any disciplinary action taken against me to its participating Entities at which I have Participation, and as may be otherwise required by law. As used herein, "Disciplinary Information" means information concerning (i) any action taken by such health care organizations, their administrators, or their medical or other committees to revoke, deny, suspend, restrict, or condition my Participation or impose a corrective action plan; (ii) any other disciplinary action involving me, including, but not limited to, discipline in the employment context; or (iii) my resignation prior to the conclusion of any disciplinary pro- ceedings or prior to the commencement of formal charges, but after I have knowledge that such formal charges were being (or are being) contemplated and/or were (or are) in preparation.

Release from Liability. I release from all liability and hold harmless any Entity, its Agent(s), and any other third party for their acts performed in good faith and with- out malice unless such acts are due to the gross negligence or willful misconduct of the Entity, its Agent(s), or other third party in connection with the gathering, release and exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release. I further agree not to sue any Entity, any Agent(s), or any other third party for their acts, defamation or any other claims based on statements made in good faith and without malice or misconduct of such Entity,Agent(s) or third party in connection with the credentialing process. This release shall be in addition to, and in no way shall limit, any other applicable immuni- ties provided by law for peer review and credentialing activities. In this Authorization, Attestation and Release, all references to the Entity, its Agent(s), and/or other third party include their respective employees, directors, officers, advisors, counsel, and agents. The Entity or any of its affiliates or agents retains the right to allow access to the application information for purposes of a credentialing audit to customers and/or their auditors to the extent required in connection with an audit of the credentialing processes and provided that the customer and/or their auditor executes an appropriate confidentiality agreement. I understand and agree that this Authorization, Attestation and Release is irrevocable for any period during which I am an applicant for Participation at an Entity, a member of an Entity's medical or health care staff, or a participating provider of an Entity. I agree to execute another form of consent if law or regulation limits the application of this irrevocable authori- zation. I understand that my failure to promptly provide another consent may be grounds for termination or discipline by the Entity in accordance with the applicable bylaws, rules, and regulations, and requirements of the Entity, or grounds for my termination of Participation at or with the Entity. I agree that information obtained in accordance with the provisions of this Authorization, Attestation and Release is not and will not be a violation of my privacy.

I certify that all information provided by me in my application is current, true, correct, accurate and complete to the best of my knowledge and belief, and is furnished in good faith. I will notify the Entity and/or its Agent(s) within 10 days of any material changes to the information (including any changes/challenges to licenses, DEA, insurance, malpractice claims, NPDB/HIPDB reports, discipline, criminal convictions, etc.) I have provided in my application or authorized to be released pursuant to the credentialing process. I understand that corrections to the application are permitted at any time prior to a determination of Participation by the Entity, and must be submitted online or in writing, and must be dated and signed by me (may be a written or an electronic signature). I acknowledge that the Entity will not process an application until they deem it to be a complete application and that I am responsible to provide a complete application and to produce adequate and timely informa- tion for resolving questions that arise in the application process. I understand and agree that any material misstatement or omission in the application may constitute grounds for withdrawal of the application from consideration; denial or revocation of Participation; and/or immediate suspension or termination of Participation. This action may be disclosed to the Entity and/or its Agent(s). I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release and that I have access to the bylaws of applicable medical staff organizations and agree to abide by these bylaws, rules and regulations. I understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.

Signature*	Name (print)*

DATE SIGNED* (MM/DD/YYYY)

PAGE 18

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

UDCF 1.1.08

	Practice Location Information
				Supplemental Form
	* REQUIRED RESPONSE (IF THIS PAGE IS USED). NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
Section 1	Practice Location Information - Page 1 of 2
Additional	LOCATION*	#
Practice	LOCATION*	#
Practice
Location	CURRENTLY			PREVIOUS
	CURRENTLY			PREVIOUS
	PRACTICING AT	YES	NO	OR FUTURE
	THIS ADDRESS?*			START DATE?
IMPORTANT
In the box provided,	DENTAL GROUP / PRACTICE NAME TO APPEAR IN DIRECTORY (DO NOT ABBREVIATE)*
indicate to which
indicate to which
practice location this
page belongs.
For example, if you	GROUP / CORPORATE NAME AS IT APPEARS ON W-9, IF DIFFERENT FROM ABOVE (DO NOT ABBREVIATE)
practice at three
locations, the primary
location is reported in	NUMBER*		STREET*			SUITE/BUILDING
the main application	NUMBER*		STREET*			SUITE/BUILDING
the main application
and remaining
locations would be
reported on	CITY*				STATE*	ZIP CODE*
Supplemental Forms	SEND GENERAL
as Location 2 and	SEND GENERAL	YES	NO
as Location 2 and	CORRESPON-	YES	NO
Location 3.	CORRESPON-
Location 3.	DENCE HERE?*
				TELEPHONE*	FAX
TIP Your Individual Tax
ID is assumed to be	OFFICE E-MAILADDRESS
ID is assumed to be
your Primary Tax ID					PRIMARY	USE INDIVIDUAL	USE GROUP
unless you specify					TAX ID	TAX ID	TAX ID
unless you specify					(ONE ONLY)*	TAX ID	TAX ID
otherwise to the right.					(ONE ONLY)*
otherwise to the right.	INDIVIDUAL TAX ID			GROUP TAX ID
	INDIVIDUAL TAX ID			GROUP TAX ID
Office Manager
or Business
Office Contact	LAST NAME*
List each contact
separately. You may	FIRST NAME*						M.I.
use the check boxes	FIRST NAME*						M.I.
use the check boxes
below for convenience.
Do not write
instructions like Òsee	TELEPHONE*			FAX
aboveÓ. These
responses will be
rejected and will
require follow-up.	E-MAILADDRESS
Billing Contact
	LAST NAME*
CHECK HERE TO
USE OFFICE
MANAGER AND
OFFICE ADDRESS	FIRST NAME*						M.I.
AS BILLING	FIRST NAME*						M.I.
AS BILLING
INFORMATION
	NUMBER*		STREET*			SUITE/BUILDING
NOTE:	CITY*				STATE*	ZIP CODE*
Even if you checked
the boxes above,	TELEPHONE*			FAX
please provide the	TELEPHONE*			FAX
please provide the
e-mail address of the
Billing Contact, if
available.	E-MAILADDRESS
	E-MAILADDRESS

* REQUIRED RESPONSE (IF THIS PAGE IS USED). NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 19

UDCF 1.1.08

Practice Location Information

Supplemental Form

*REQUIRED RESPONSE (IF THIS PAGE IS USED). NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 1

Practice Location Information - Page 2 of 2

Add’l Practice

LOCATION* #

Location (Cont.)

Payment and

ELECTRONIC

YES

Remittance

BILLING

CAPABILITIES?*

BILLING DEPARTMENT (IF HOSPITAL-BASED)

YOUR “CHECK PAYABLE TO”

INFORMATION SHOULD BE

CONSISTENT WITH YOUR

W-9.

CHECK PAYABLE TO*

CHECK HERE TO

USE OFFICE

LAST NAME*

MANAGER AND

OFFICE ADDRESS

AS BILLING

INFORMATION

FIRST NAME*

M.I.

NUMBER*

STREET*

SUITE/BUILDING

NOTE:

Even if you checked

CITY*

STATE*

ZIP CODE*

the boxes above,

please provide the

E-mail Address,

TELEPHONE*

FAX

Department Name,

Electronic Billing and

Check Payable To, if

applicable.

E-MAILADDRESS

Office Hours

(USE HHMM FORMATAND ROUND TO THE NEAREST HALF-HOUR)

START

A=AM

END

A=AM

START

A=AM

END

A=AM

P=PM

MONDAY

FRIDAY

TUESDAY

SATURDAY

NOTE:

WEDNESDAY

SUNDAY

After hours back office

THURSDAY

telephone will be used

only by the health plan

and will not be

24/7 PHONE COVERAGE?*

IF YES

published under any

ANSWERING

VOICE MAIL WITH

VOICE MAIL

COVERING

circumstances.

YES

INSTRUCTIONS TO CALL

WITH OTHER

SERVICE

COLLEAGUE

ANSWERING SERVICE

INSTRUCTIONS

Open Practice

ACCEPT NEW PATIENTS INTO THIS PRACTICE?*

YES

ACCEPT ALL NEW PATIENTS?*

YES

Status

YES

ACCEPT EXISTING PATIENTS WITH CHANGE OF PAYOR?*

YES

ACCEPT NEW MEDICAID PATIENTS?*

ACCEPT NEW PATIENTS WITH PHYSICIAN REFERRAL?*

YES

IF ANY OF THE

ABOVE INFORMATION

VARIES BY PLAN,

EXPLAIN

ARE THERE ANY

PRACTICE LIMITATIONS?*

YES

IF YES,

EXPLAIN

CURRENT WAIT TIME FOR

NUMBER OF OPERATORS

INITIALAPPOINTMENT

AVAILABLE

* REQUIRED RESPONSE (IF THIS PAGE IS USED). NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 20

MIA_UDCF 1.1.08

Professional Liability Insurance Carrier

Supplemental Form

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 2

Professional Liability Insurance Carrier

Other

SELF-INSURED?

YES

Professional

Liability

CARRIER OR SELF-INSURED NAME

Insurance

Carrier

NUMBER*

STREET*

SUITE/BUILDING

List secondary /

second layer / future or

CITY*

STATE*

ZIP CODE*

previous carrier(s).

For second layer

TYPE OF

INDIVIDUAL

SHARED

COVERAGE?*

coverage list name of

ORIGINAL EFFECTIVE DATE*

EFFECTIVE DATE* (MM/YYYY)

EXPIRATION DATE (MM/YYYY)

hospital/organization

(MM/YYYY)

providing coverage

DO YOU HAVE UNLIMITED COVERAGE

YES

WITH THIS INSURANCE CARRIER?

AMOUNT OF COVERAGE PER OCCURRENCE

AMOUNT OF COVERAGE AGGREGATE

POLICY INCLUDES TAIL COVERAGE?

YES

POLICY NUMBER*

Other

SELF-INSURED?

YES

Professional

Liability

CARRIER OR SELF-INSURED NAME

Insurance

Carrier

NUMBER*

STREET*

SUITE/BUILDING

List secondary /

second layer / future or

CITY*

STATE*

ZIP CODE*

previous carrier(s).

For second layer

TYPE OF

INDIVIDUAL

SHARED

COVERAGE?*

coverage list name of

ORIGINAL EFFECTIVE DATE*

EFFECTIVE DATE* (MM/YYYY)

EXPIRATION DATE (MM/YYYY)

hospital/organization

(MM/YYYY)

providing coverage

DO YOU HAVE UNLIMITED COVERAGE

YES

WITH THIS INSURANCE CARRIER?

If you need additional

AMOUNT OF COVERAGE PER OCCURRENCE

AMOUNT OF COVERAGE AGGREGATE

space for Insurance

Coverage, photocopy

POLICY INCLUDES TAIL COVERAGE?

YES

this page as needed

and submit as

instructed.

POLICY NUMBER*

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 21

UDCF 1.1.08

			Disclosure Questions
			Supplemental Form
	* REQUIRED RESPONSE (IF THIS PAGE IS USED). NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
Section 3		Disclosure Questions
Disclosure		QUESTION # EXPLANATION
Questions

Use this form to report any ÒYesÓ response to one or more of the Disclosure Questions in Section 8. Your response should not exceed the spaces provided.

Record the question number in the first column, then your explanation in the second column.

If you need additional space to explain a Yes response, photocopy this page as needed and submit as instructed.

QUESTION #		EXPLANATION

QUESTION #		EXPLANATION

* REQUIRED RESPONSE (IF THIS PAGE IS USED). NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 22

UDCF 1.1.08

Malpractice Claims Explanation

Supplemental Form

*REQUIRED RESPONSE (IF THIS PAGE IS USED). NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 4

Malpractice Claims Explanation

Malpractice

DATE OF

DATE CLAIM

Claims

OCCURRENCE*

WAS FILED*

Explanation

(MM/DD/YYYY)

STATUS OF CLAIM* (NOTE: IF CASE IS PENDING, SELECT OPEN)

Use this form to report

IF SETTLED, ENTER DATE

any ÒYesÓ response to

OPEN

CLOSED

CLAIM WAS SETTLED

Disclosure Question

(MM/DD/YYYY)

#19.

If you need additional

space to explain a Yes

response, photocopy

this page as needed

PROFESSIONAL LIABILITY CARRIER INVOLVED* (USE BOTH LINES IF NECESSARY)

and submit as

instructed.

NUMBER*

STREET*

SUITE/BUILDING

CITY*

STATE*

ZIP CODE*

TELEPHONE

POLICY NUMBER

METHOD OF

DISMISSED

SETTLED

MEDIATION

ARBITRATION

RESOLUTION?*

AMOUNT OF AWARD OR SETTLEMENT*

JUDGMENT FOR

DEFENDANT(S)

PLAINTIFF(S)

DESCRIPTION OF ALLEGATIONS* (USE ALL FOUR LINES BELOW, IF NECESSARY)

WERE YOU THE PRIMARY DEFENDANT OR CO-DEFENDANT?*

PRIMARY

DEFENDANT

	CO-DEFENDANT	NUMBER OF OTHER
	CO-DEFENDANT	CO-DEFENDANTS (IF ANY)
		CO-DEFENDANTS (IF ANY)

YOUR INVOLVEMENT IN CASE* (ATTENDING, CONSULTING, ETC)

DESCRIPTION OF ALLEGED INJURY TO THE PATIENT (USE ALL FOUR LINES BELOW, IF NECESSARY)

DID THE ALLEGED INJURY RESULT IN DEATH?

YES	NO	TO THE BEST OF YOUR KNOWLEDGE, IS THE CASE INCLUDED
YES	NO	IN THE NATIONAL PRACTITIONER DATA BANK (NPDB)?*
		IN THE NATIONAL PRACTITIONER DATA BANK (NPDB)?*

YES NO

* REQUIRED RESPONSE (IF THIS PAGE IS USED). NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

PAGE 23

UDCF 1.1.08

Code Lists

Provider Type Codes

001 Medical Doctor (MD)

004 Other

002Doctor of Dental Surgery (DDS)

003Doctor of Dental Medicine (DMD)

License Status Codes

001	Active	008	Pending	015	Temporary
002	Canceled	009	Probation	016	Terminated
003	Denied	010	Provisional	017	Time Limited
004	Expired	011	Restricted	018	Unrestricted
005	Inactive	012	Revoked	019	Other
006	Lapsed	013	Suspended
007	Limited	014	Surrendered

Country Codes

004	Afghanistan	626	East Timor (provisional)	434	Libya	670	Saint Vincent and the
008	Albania	218	Ecuador	438	Liechtenstein		Grenadines
012	Algeria	818	Egypt	440	Lithuania	882	Samoa
016	American Samoa	222	El Salvador	442	Luxembourg	674	San Marino
020	Andorra	226	Equatorial Guinea	446	Macau	678	S‹o TomŽ and Pr’ncipe
024	Angola	232	Eritrea	807	Macedonia	682	Saudi Arabia
660	Anguilla	233	Estonia	450	Madagascar	683	Scotland
010	Antarctica	231	Ethiopia	454	Malawi	686	Senegal
028	Antigua and Barbuda	238	Falkland Islands (Malvinas)	458	Malaysia	690	Seychelles
032	Argentina	234	Faroe Islands	462	Maldives	694	Sierra Leone
051	Armenia	242	Fiji	466	Mali	702	Singapore
533	Aruba	246	Finland	470	Malta	703	Slovakia
036	Australia	250	France	584	Marshall Islands	705	Slovenia
040	Austria	249	France, Metropolitan	474	Martinique	090	Solomon Islands
031	Azerbaijan	254	French Guiana	478	Mauritania	706	Somalia
044	Bahamas	258	French Polynesia	480	Mauritius	710	South Africa
048	Bahrain	260	French Southern Territories	175	Mayotte	239	South Georgia and the South
050	Bangladesh	266	Gabon	484	Mexico		Sandwich Islands
052	Barbados	270	Gambia	583	Micronesia	724	Spain
112	Belarus	268	Georgia	498	Moldova	144	Sri Lanka
056	Belgium	276	Germany	492	Monaco	736	Sudan
084	Belize	288	Ghana	496	Mongolia	740	Suriname
204	Benin	292	Gibraltar	500	Montserrat	744	Svalbard and Jan Mayen
060	Bermuda	300	Greece	504	Morocco	748	Swaziland
064	Bhutan	304	Greenland	508	Mozambique	752	Sweden
068	Bolivia	308	Grenada	104	Myanmar	756	Switzerland
070	Bosnia and Herzegovina	312	Guadaloupe	516	Namibia	760	Syria
072	Botswana	316	Guam	520	Nauru	158	Taiwan
074	Bouvet Island	320	Guatemala	524	Nepal	762	Tajikistan
076	Brazil	324	Guinea	528	Netherlands	834	Tanzania
086	British Indian Ocean Territory	624	Guinea-Bissau	530	Netherlands Antilles	764	Thailand
096	Brunei Darussalam	328	Guyana	540	New Caledonia	768	Togo
100	Bulgaria	332	Haiti	554	New Zealand	772	Tokelau
854	Burkina Faso	334	Heard Island and McDonald	558	Nicaragua	776	Tonga
108	Burundi		Islands	562	Niger	780	Trinidad and Tobago
116	Cambodia	340	Honduras	566	Nigeria	788	Tunisia
120	Cameroon	344	Hong Kong	570	Niue	792	Turkey
124	Canada	348	Hungary	574	Norfolk Island	795	Turkmenistan
132	Cape Verde	352	Iceland	580	Northern Mariana Islands	796	Turks and Caicos Islands
136	Cayman Islands	356	India	578	Norway	798	Tuvalu
140	Central African Republic	360	Indonesia	512	Oman	800	Uganda
148	Chad	364	Iran	586	Pakistan	804	Ukraine
152	Chile	368	Iraq	585	Palau	784	United Arab Emirates
156	China	372	Ireland	591	Panama	826	United Kingdom
162	Christmas Island	376	Israel	598	Papua New Guinea	840	United States
166	Cocos (Keeling) Islands	380	Italy	600	Paraguay	581	U.S. Minor Outlying Islands
170	Colombia	388	Jamaica	604	Peru	858	Uruguay
174	Comoros	392	Japan	608	Philippines	860	Uzbekistan
178	Congo	400	Jordan	612	Pitcairn	548	Vanuatu
180	Congo, Democratic Republic of the	398	Kazakhstan	616	Poland	336	Vatican City State (Holy See)
184	Cook Islands	404	Kenya	620	Portugal	862	Venezuela
188	Costa Rica	296	Kiribati	630	Puerto Rico	704	Viet Nam
384	Cote d'Ivoire	408	Korea, North	634	Qatar	092	Virgin Islands, British
191	Croatia	410	Korea, South	638	RŽunion	850	Virgin Islands, U.S.
192	Cuba	414	Kuwait	642	Romania	876	Wallis and Fortuna Islands
196	Cyprus	417	Kyrgyzstan	643	Russian Federation	732	Western Sahara (provisional)
203	Czech Republic	418	Laos	646	Rwanda	887	Yemen
208	Denmark	428	Latvia	654	Saint Helena	891	Yugoslavia
262	Djibouti	422	Lebanon	659	Saint Kitts and Nevis	894	Zambia
212	Dominica	426	Lesotho	662	Saint Lucia	716	Zimbabwe
214	Dominican Republic	430	Liberia	666	Saint Pierre and Miquelon

PAGE 24

UDCF 1.1.08

Code Lists

Language Codes

001	Abkhazian	036	Frisian	071	Macedonian	106	Slovak
002	Afan (Oromo)	037	Galican	072	Malagasy	107	Slovenian
003	Afar	038	Georgian	073	Malay	108	Somali
004	Afrikaans	039	German	074	Malayalam	109	Spanish
005	Albanian	040	Greek	075	Maltese	110	Sundanese
006	Amharic	041	Greenlandic	076	Maori	111	Swahili
007	Arabic	042	Guarani	077	Marathi	112	Swedish
008	Armenian	043	Gujarati	078	Moldavian	113	Tagalog
009	Assamese	044	Hausa	079	Mongolian	114	Tajik
010	Zerbaijani	045	Hebrew	080	Nauru	115	Tamil
011	Bashkir	046	Hindi	081	Nepali	116	Tatar
012	Basque	047	Hungarian	082	Norwegian	117	Telugu
013	Bengali;Bangla	048	Icelandic	083	Occitan	118	Thai
014	Bhutani	049	Indonesian	084	Oriya	119	Tibetan
015	Bihari	050	Interlingua	085	Pashto;Pushto	120	Tigrinya
016	Bislama	051	Interlingue	086	Persian (Farsi)	121	Tonga
017	Breton	052	Inuktitut	087	Polish	122	Tsonga
018	Bulgarian	053	Inupiak	088	Portuguese	123	Turkish
019	Burmese	054	Irish	089	Punjabi	124	Turkmen
020	Byelorussian	055	Italian	090	Quechua	125	Twi
021	Cambodian	056	Japanese	091	Rhaeto-Romance	126	Uigur
022	Catalan	057	Javanese	092	Romanian	127	Ukrainian
023	Chinese	058	Kannada	093	Russian	128	Urdu
024	Corsican	059	Kashmiri	094	Samoan	129	Uzbek
025	Croatian	060	Kazakh	095	Sangho	130	Vietnamese
026	Czech	061	Kinyarwanda	096	Sanskrit	131	Volapuk
027	Danish	062	Kirghiz	097	Scot Gaelic	132	Welsh
028	Dutch	063	Kurundi	098	Serbian	133	Wolof
140	English	064	Korean	099	Serbo-Croatian	134	Xhosa
030	Esperonto	065	Kurdish	100	Sesotho	135	Yiddish
031	Estonian	066	Laothian	101	Setswana	136	Yoruba
032	Faroese	067	Latin	102	Shona	10	Zerbaijani
033	Fiji	068	Latvian;Lettish	103	Sindhi	137	Zhuang
034	Finnish	069	Lingala	104	Singhalese	138	Zulu
035	French	070	Lithuanian	105	Siswati

U.S. / Canadian Professional School Codes

Alabama		Indiana
300	University of Alabama School of Dentistry	316	Indiana University School of Dentistry
Arizona		Kentucky
900	Arizona School of Dentistry and Oral Health	317	University of Kentucky College of Dentistry
		318	University of Louisville School of Dentistry
California
301	Loma Linda University School of Dentistry	Louisiana
302	University of California, Los Angeles School of Dentistry	319	Louisiana State University School of Dentistry
303	University of California, San Francisco, School of Dentistry
304	University of Southern California School of Dentistry	Massachusetts
305	University of the Pacific School of Dentistry	320	Boston University, Goldman School of Dental Medicine
		321	Harvard School of Dental Medicine
Colorado		322	Tufts University School of Dental Medicine
306	University of Colorado School of Dentistry
		Maryland
Connecticut		323	University of Maryland, Baltimore, College of Dental Surgery
307	University of Connecticut School of Dental Medicine
		Michigan
District of Columbia		324	University of Detroit Mercy School of Dentistry
308	Howard University College of Dentistry	325	University of Michigan School of Dentistry
Florida		Minnesota
309	Nova Southeastern University College of Dentistry	326	University of Minnesota School of Dentistry
310	University of Florida College of Dentistry
		Missouri
Georgia		327	University of Missouri Kansas City School of Dentistry
311	Medical College of Georgia School of Dentistry
		Mississippi
Iowa		328	University of Mississippi School of Dentistry
312	University of Iowa College of Dentistry
		North Carolina
Illinois		329	University of North Carolina at Chapel Hill School of Dentistry
313	Northwestern University Dental School
314	Southern Illinois University School of Dental Medicine	Nebraska
315	University of Illinois at Chicago College of Dentistry	330	Creighton University School of Dentistry
		331	University of Nebraska Medical Center, College of Dentistry

PAGE 25

UDCF 1.1.08

Code Lists

U.S. / Canadian Professional School Codes (continued)

Nevada		Virginia
901	University of Nevada Las Vegas School of Dental Medicine	351	Virginia Commonwealth University School of Dentistry
New Jersey		Washington
332	UMDNJ, New Jersey Dental School	352	University of Washington School of Dentistry
New York		Wisconsin
333	Columbia University School of Dental and Oral Surgery	353	Marquette University School of Dentistry
334	New York University Kriser Dental Center
335	State University of New York at Buffalo School of Dental Medicine	West Virginia
336	State University of New York at Stony Brook School of Dental Medicine	354	West Virginia University School of Dentistry
Ohio		Canada
337	Case Western Reserve University School of Dentistry	355	Dalhousie University Faculty of Dentistry
338	Ohio State University College of Dentistry	357	Laval University Faculty of Dentistry
		356	McGill University Faculty of Dentistry
Oklahoma		132	The University of Western Ontario Faculty of Medicine & Dentistry
339	University of Oklahoma College of Dentistry	358	University of Alberta Faculty of Dentistry
		359	University of British Columbia Faculty of Dentistry
Oregon		360	University of Manitoba Faculty of Dentistry
340	Oregon Health Sciences University School of Dentistry	138	University of Manitoba Faculty of Medicine
		361	University of Montreal Faculty of Dentistry
Pennsylvania		362	University of Saskatchewan College of Dentistry
341	Temple University School of Dentistry	363	University of Toronto Faculty of Dentistry
342	University of Pennsylvania School of Dental Medicine	364	University of Western Ontario Faculty of Dentistry
343	University of Pittsburgh School of Dental Medicine
		Other
Puerto Rico		999
344	University of Puerto Rico School of Dentistry

Rhode Island

South Carolina

345 Medical University of South Carolina College of Dental Medicine

South Dakota

Tennessee

346Meharry Medical College School of Dentistry

347University of Tennessee College of Dentistry

Texas

348Baylor College of Dentistry

349University of Texas Health Science Center at Houston Dental School

350University of Texas Health Science Center at San Antonio Dental School

Specialty Codes - DDS / DMD

NOTE: THIS LIST IS FROM THE NATIONAL HEALTH CARE PROVIDER TAXONOMY CODE LIST, PUBLISHED IN COOPERATION WITH THE NATIONAL UNIFORM CLAIM COMMITTEE (NUCC).

DDS / DMD		16	Dentist, Oral and Maxillofacial Pathology	18	Dentist, Periodontics
2	Dentist	439	Dentist, Oral and Maxillofacial Radiology	19	Dentist, Prosthodontics
13	Dentist, Dental Public Health	20	Dentist, Oral and Maxillofacial Surgery	99	Other
14	Dentist, Endodontics	15	Dentist, Orthodontics and Dentofacial Orthopedics
438	Dentist, General Practice	17	Dentist, Pediatric Dentistry

Specialty Boards - Dental

113	American Board of Endodontics	112	American Board of Pediatric Dentistry
114	American Board of Oral & Maxillofacial Pathology	111	American Board of Periodontology
117	American Board of Oral & Maxillofacial Radiology	115	American Board of Prosthodontics
109	American Board of Oral & Maxillofacial Surgeons	106	American Board of Public Health Dentistry
108	American Board of Orthodontics	120	Boards other than ABMS/AOA

PAGE 26

UDCF 1.1.08

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