Social Security Number Date of Birth Taxpayer Identification Number
To help us comply with the State of Tennessee Diversity Program, would you please check the appropriate boxes? ____Male ____Asian _____Black ____Caucasian
____Female ____Hispanic _____Other ____Prefer not to respond
II. OFFICE INFORMATION If you have additional offices, please include this information on a separate attachment. PRIMARY OFFICE SECONDARY OFFICE
Name of Practice Name of Practice
and the name and address of the professional liability insurer involved.)
In order to be credentialed by Delta Dental, you are required to provide proof of professional liability (malpractice) insurance. So that this requirement might be fulfilled, please complete the Authorization Form included on page 4. This authorization permits your carrier/agent to provide us with copies of future renewals; thereby eliminating the need for you to do so. Also, please enclose a copy of the declaration page of your policy.
I authorize the State Board (or any other dental licensing agencies in any state in which I am licensed to practice dentistry) and any health care facility, health maintenance organization or professional organization with whom I have had employment, practice, association or privileges, to release information to Delta Dental of Tennessee regarding my professional skills, any pending or final disciplinary action or malpractice action, and any other information relevant to my character or professional competence. I authorize and request my professional liability (malpractice) insurance carrier to release information to Delta Dental of Tennessee regarding any claims or actions for damages pending or closed, whether or not there has been a final disposition. Further, I authorize such carrier to provide evidence of professional liability coverage to Delta Dental of Tennessee upon its request. I release from liability: a) any person or entity who, in good faith and without malice, provides information to Delta Dental of Tennessee for the purpose of evaluating this Credentialing Profile; and b) Delta Dental of Tennessee for their acts performed in good faith and without malice in connection with evaluating this Credentialing Profile.
I certify that all of the information herein is accurate and true to the best of my knowledge and agree to notify Delta Dental of Tennessee, in writing, of any changes in this document within ten (10) days of their occurrence. I understand that information which is found to be false could result in denial/termination of my participation with Delta Dental of Tennessee.
A photocopy of this permission will be considered as valid as the original.