Provider File



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Provider File

License # _________________________________


Name ____________________________________
Effective Date: ________________________, 2016
Enter Date: ___________________________, 2016
Operator: _________________________________
Notes: ____________________________________

For Delta Dental Use Only


Delta Dental of Minnesota

P.O. Box 9304

Minneapolis, MN 55440-9304

Confidential Filed Fee Schedule


(Updated to include CDT 2016 code terminology)


Statement of Intent:

I agree that each fee submitted to Delta Dental on a claim for dental services I provide to any Delta Dental patient will be these pre-filed fees or the fees actually charged and accepted as payment in full, whichever is less, consistent with the rules and regulations of Delta Dental. If requested by Delta Dental, I will verify by providing documentary evidence satisfactory to Delta Dental that the fees listed on this schedule are my normal (most frequently charged) fees for dental procedures uniformly charged to patients or third party payors. I understand that I cannot revise my pre-filed fees until after the expiration of six (6) months from the effective date indicated below. My fees as pre-filed with Delta Dental on this schedule include the amount of any applicable MinnesotaCare tax.



Note:
Fees must be filed with Delta Dental 30 days prior to their effective date to ensure proper payment of claims. Fee ranges per procedure are not accepted. Please retain a copy of this form with your records.
These new fees are effective on __________________________________________, 2016




Dentist Information: To ensure an accurate update, ALL dentists and ALL locations must be given.

This fee schedule applies to the following dentist(s) at the following locations(s) ONLY. Please attach additional sheets if necessary.






Dentist Personal Signature


Dentist Name (print)


Tax Identification


License



NPI Number



Street Address



City



State



Zip



Dentist Personal Signature


Dentist Name (print)


Tax Identification


License



NPI Number



Street Address



City



State



Zip



Dentist Personal Signature


Dentist Name (print)


Tax Identification


License



NPI Number



Street Address



City



State



Zip



Dentist Personal Signature


Dentist Name (print)


Tax Identification


License



NPI Number



Street Address



City



State



Zip
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