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1310 Vermillion St #8 Hastings, MN 55033 Vox 800-482
1310 Vermillion St #8 ● Hastings, MN 55033 Vox 800-482-3518 ● Fax 651-389-9152 Atlantic Dental Inc DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION CX052 PAYER ID NUMBER ELECTRONIC REGISTRATIONS Electronic Dental Service Enrollment Form • • Agreements Required SPECIAL NOTES • Atlantic Dental Inc. requires the provider be credentialed with them. Upon completion of the credentialing process ADI assigns both a provider id and a location id. ADI requires both of these numbers appear within the claim. • If a provider is unsure of their credentialing status or if they wish to begin the credentialing process they must call ADI at 305-443-3111 ext 2230 or ext 2232 for Provider Relations. Electronic Dental Service 1310 Vermillion St #8 Hastings, MN 55033 Attn: Provider Enrollment Or Fax to: 651-389-9152 SEND REGISTRATION FORMS TO ENROLLMENT CONFIRMATION CHANGING ELECTRONIC BILLING AGENTS Please complete all requested information. Provider ID and Location ID assigned by ADI MUST be included. • Once Electronic Dental Service has received the Provider Enrollment Form, Atlantic Dental Inc. will be contacted with a request for credential verification. • Once approval is received from Atlantic Dental Inc, the provider or their software vendor will be contacted that they may begin sending electronic claims. If the Provider currently submits claims through another Billing Agent other than Electronic Dental Service each Provider must re-enroll following the procedures listed above. 11/29/2006 Page 1 of 3 1310 Vermillion St #8 ● Hastings, MN 55033 Vox 800-482-3518 ● Fax 651-389-9152 CONTACT PHONE NUMBERS Electronic Dental Service Provider Enrollment 800-482-3518 ADI Provider Relations 305-443-3111 ext 2230 or ext 2232 11/29/2006 Page 2 of 3 1310 Vermillion St #8 ● Hastings, MN 55033 Vox 800-482-3518 ● Fax 651-389-9152 Print/Type the following: Insurance Carrier: Atlantic Dental Inc. Provider/Organization Name: _______________________________________ Tax Identification or Social Security Number: ___________________________ (This is the number that will be used to submit electronic claims) Software Vendor: _________________________________________________ Location Number: __________________________ Rendering Name and Number: _________________________________ _______________________________ _________________________________ _______________________________ _________________________________ _______________________________ _________________________________ _______________________________ Address: _______________________________________________________ City, State, Zip Code: _____________________________________________ Office Contact Name: _____________________________________________ Telephone Number: __________________ Fax Number: ________________ Date: _____________________________ 9/19/2005 Page 2 of 2
