12121 North Corporate Parkway, Mequon, WI (262) or (800) Fax (262)

Transcription

1 12121 rth Corporate Parkway, Mequon, WI (262) or (800) Fax (262) **INCOMPLETE APPLICATIONS WILL DELAY THE CREDENTIALING PROCESS** The following documents are REQUIRED for credentialing and consideration for privileges to participate in the DentaQuest, LLC (DentaQuest) network. 1. A COMPLETED Provider Application that is signed and dated. 2. A copy of CURRENT valid state license to practice dentistry. 3. National Provider Identifier Number 4. A copy of CURRENT professional liability insurance policy that indicates carrier name, policy number, expiration dates and policy limits. 5. A copy of professional liability claims history (if applicable). PLEASE INDICATE: New Provider, New Location Adding Additional Location New Provider, Existing Location Other Please add to our current contract under (Provider Name) (Entity Name) with Tax ID #. Name of Applicant Last Name First Name Middle Name Specialty Office Contact for Credentialing Information PLEASE REMEMBER: PROVIDER CANNOT BEGIN TO TREAT MEMBERS UNTIL FINAL APPROVAL FROM DENTAQUEST IS RECEIVED DentaQuest Credentialing Process Credentialing is the process of verifying credentials (i.e. training, licensing, hospital affiliations) of potential providers by primary sources. DentaQuest takes pride in its network of providers and is proud to say that all providers are credentialed following the guidelines of the National Committee for Quality Assurance (NCQA) to ensure our members that they are receiving the best quality care possible. Using NCQA guidelines for credentialing will ensure an organization that the providers affiliated with their panel are the best in the dental field. Revised

2 PROVIDER APPLICATION GENERAL INFORMATION Last Name First Name Middle Initial Date of Birth (MM/DD/YY) Provider Gender: Provider Race/Ethnicity: Address: Male Female American Indian/Alaska Native Black/African American Native Hawaiian or Other Pacific Islander Asian Hispanic White ( ) ( ) Primary Office Name Office Contact Telephone Number Fax Number Primary Office Address City State Zip Code County ( ) ( ) Secondary Office Name Office Contact Telephone Number Fax Number Secondary Office Address City State Zip Code County BILLING INFORMATION Federal Tax Identification Name (Name to which payments should be made) Federal Tax Identification Number Billing Office Address City State Zip Code ( ) ( ) Billing Office Contact Name / Title Telephone Number Fax Number License Plate Number (Mobile Units Only) If you practice at more than one location, do you require separate checks for each location? If yes, please indicate payment information for secondary office below. Federal Tax Identification Name (Name to which payments should be made) Federal Tax Identification Number Billing Office Address City State Zip Code Billing Office Contact Name / Title Specialty Board(s) by which you are certified ( ) ( ) Telephone Number Fax Number AMERICAN BOARD CERTIFICATION License Plate Number (Mobile Units Only) Name Date Certified Expiration Date Recertification Date PRACTICE INFORMATION Practice Type (check one) Adults Only Children Only Adults & Children If you see children, minimum age What percentage of your patients are treated in an outpatient operating room setting? % List all Hospitals at which you have admitting privileges: Hospital Name Address City State Hospital Name Address City State Hospital Name Address City State Revised

3 Office Hours Primary Location Office Hours Secondary Location OFFICE INFORMATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday Do you have coverage after normal business hours? If yes, please list contact information: Languages spoken at office (check all that apply) English Spanish Arabic Chinese French German Hmong Hindi Laotian Philippine Vietnamese Other Is your office capable of handling hearing or visually impaired individuals? Is your office handicapped accessible? Number of treatment chairs: Type of x-ray machine: Conventional Panorex Does your office have a personal computer? LICENSE/IDENTIFICATION NUMBERS Social Security Number Professional License Number/State/Exp Date DEA Number Expiration Date Please Check the Schedules that apply on your DEA certificate: 2 2N 3 3N 4 5 All Schedules *If you do not carry a DEA license please provide an explanation as to why and the name of the provider who will prescribe on your behalf, should a patient require medications Do you administer Intravenous or Conscious Sedation? If yes, please attach a copy of your current, valid anesthesia license. Anesthesia License Number State Expiration Date Individual NPI Information NPI INFORMATION Please check box if Sole Proprietor. ALL providers MUST complete NPI information. INDIVIDUAL NPI Number NPI Type NPI Effective Date DentaQuest s Provider ID Taxonomy Code Group / Organization NPI Information (REQUIRED unless you are a Sole Proprietor) GROUP NPI Number NPI Type NPI Effective Date DentaQuest s Provider ID Taxonomy Code Sub-Part Information (Optional may be necessary to identify multiple locations.) SUB-PART NPI Number NPI Number NPI Type NPI Effective Date DentaQuest s Provider ID SUB-PART NPI Type NPI Effective Date DentaQuest s Provider ID Taxonomy Code Taxonomy Code Revised

4 NPI Number SUB-PART NPI Type NPI Effective Date DentaQuest s Provider ID SUB-PART Taxonomy Code NPI Number NPI Type NPI Effective Date DentaQuest s Provider ID PROFESSIONAL EMPLOYMENT HISTORY Chronologically list all present and previous work history related to your professional employment within the past five (5) years. Please provide a written explanation of any gaps grater than 6 months. What was your start date at primary location? / / (day / month / year) Taxonomy Code Hire Date (MM/YY) Termination Date (MM/YY) Employer Location Address Reason for Leaving EDUCATION / TRAINING Professional School Name City/State Degree(s) Date Received Internship / Residency City / State Specialty Beginning / Ending Dates Institution Name City / State Specialty Beginning / Ending Dates PROFESSIONAL LIABILITY (MALPRACTICE) INSURANCE List ALL insurance carriers for the past 5 years. Attach additional sheets if necessary. Name of current Carrier Mailing Address Phone # Fax # Policy # Effective Date Expiration Date Amounts of Coverage: Occurrence/Claim $ Aggregate $ Previous Carrier Mailing Address Phone # Fax # Policy # Effective Date Expiration Date Amounts of Coverage: Occurrence/Claim $ Aggregate $ Previous Carrier Mailing Address Phone # Fax # Policy # Effective Date Expiration Date Amounts of Coverage: Occurrence/Claim $ Aggregate $ Revised

5 For Mobile Dental Clinics or Portable Dental Operations Only: Is your mobile dental clinic or portable dental operation operated by a federal, state or local governmental agency? Does your mobile dental clinic or portable dental operation provide dental treatment without charge to patients or to any third party payer and which is not provided on a regular basis (recurring at fixed or uniform intervals)? If the answer to either of the questions above is no, is your mobile dental clinic or portable dental operation registered to legally operate in Virginia? (te: Proof of registration must be included with this application) Revised

6 QUESTIONAIRE Please mark with an X under the yes/no columns for each question. If you answer YES to any of the following questions, please provide us with a detailed explanation in the space provided below. YES NO 1. Has your Dental License been limited, suspended, denied, revoked, restricted, subject to probationary conditions, or have proceedings been instituted against you? 2. Have you voluntarily relinquished, reduced, restricted, or otherwise limited your dental license in any jurisdiction? 3. Have you been reprimanded or disciplined by any State or Commonwealth Department of Regulation and Licensure of the Dental Examining Board? 4. Has your participation for receiving payment under the Medical Assistance, Medicaid, or Medicare program been suspended or limited or have you voluntarily terminated your participation? 5. Have you been convicted of any criminal offenses, pending or otherwise, other than a minor traffic violation? 6. Have you had a judgment made against you for alleged malpractice, negligence, or related matters? Are any cases pending? 7. Have you had any judgments made against you in a professional liability case or has your liability insurer placed any conditions or restrictions on your coverage or ability to attain coverage? 8. Have any litigation settlements been made on your behalf? 9. Are you, or have you been, under the treatment for the use of narcotics, barbiturates, alcohol, or other drugs? 10. Do you presently have any physical or mental condition that would adversely affect your ability to provide high quality professional services? Are there any accommodations that need to be considered? Please list accommodations below. 11. Has your participation with a managed care organization, other health care organization or hospital privileges been suspended, limited, or terminated? 12. Has your Drug Enforcement Agency (DEA) registration been denied, revoked, suspended, or not renewed? 13. Are you currently using illegal drugs? 14. Have you verified through the Excluded Parties Listing Service that none of the employees working in your practice(s) are excluded from participating in Medicaid Programs? t Applicable, I am not the owner of the Dental Practice (If you need additional space, please attach separate sheets) Name: (Please Print) Revised

7 CERTIFICATION, STATEMENTS, AND SIGNATURE I hereby acknowledge that the information provided in this application is material to the determination by DENTAQUEST whether or not to execute an agreement with me. I hereby represent and warrant that all information provided herein is true, correct and complete to the best of my knowledge, and I agree to notify DENTAQUEST in the event an error is discovered or when new events occur which alter the validity of any response herein. I hereby authorize DENTAQUEST to consult with individuals or institutions with which I have been associated and with others, including but not limited to past and present malpractice carriers, educational institutions, and state licensing boards, who may have information bearing on my professional competence, character and ethical qualifications and authorize the release of any such written or oral verification as needed by DENTAQUEST. I hereby release from liability for any such entity, institution or organization that provides information as part of the application process. I certify that: * All parties of material interest have been identified and include no persons or entities with a potential for profit from selfreferral, * All services are provided by and under the on Premise supervision of a licensed dentist, * The above information is complete, correct and true to the best of my knowledge, * My malpractice information is current at the time of the application and the limits are at the minimum amounts required by the State and DentaQuest. Signed by: Principal Date: Please print name: All applications are subject to review and approval by DENTAQUEST. All information contained in a credentialing file will be held in strict confidence, and available for review by only duly authorized employees of DentaQuest Dental USA, LLC, DMAS, and/or third party review organizations (i.e. NCQA, etc.) Practitioner has the right to obtain a copy of their credentialing file, by submitting a written, signed request to the Supervisor of Credentialing at the corporate headquarters for DentaQuest Dental USA, LLC. Any corrections, additions, or clarifications to these files must be submitted in writing to the Supervisor of Credentialing. The practitioner has the right, upon request, to be informed of the status of their credentialing or re-credentialing application via phone, fax, or mail. If the Credentialing Committee recommends the acceptance of an application with restrictions, denial of an application, or discipline or termination of a practitioner, written notification will be issued within 30 days of that decision. The practitioner then has 30 days from the date of the notice to submit a written appeal of that decision. Appeals should be addressed to the Credentialing Committee, DentaQuest Dental USA, LLC and sent to DentaQuest s corporate address. In the event that a dentist s application for participation is rejected or limited for reasons pertaining to the applicant s professional conduct or competence, DentaQuest is required to submit a report to DMAS. DMAS will submit a report to the National Practitioner Data Bank and the state licensing board as required by law. FOR DENTAQUEST USE ONLY Initial Entry By: Date: Final Entry By: Date: Revised

8 Page 1 Disclosure of Ownership and Control Interest Statement Completion and submission of this form is a condition of participation in any program established by Medicaid or Medicare only. One full and accurate disclosure of ownership is required for each Business Entity. Failure to submit the requested information will result in refusal to participate in the DentaQuest Network or in termination of an existing agreement. If there are any changes in the ownership an updated form must be submitted. 1. Identifying Information Name of Entity DBA Tax ID Telephone Number Street Address City, County, State Zip Code 2. Answer the following questions by checking "" or "". If any of the questions are answered "", list names and addresses of individuals or corporations under Remarks on page 4. Identify each item number to be continued. a. Are there any individuals or organizations that have a direct or indirect ownership or control interest of 5% or more in the Business Entity that have been convicted of a criminal offense related to the involvement of such persons in any of the programs under Medicaid and Medicare Programs? b. Have any directors, officers, agents, or managing employees of the Business Entity that ever been convicted of a criminal offense related to their involvement in such programs established by Medicaid and Medicare? c. Are there any individuals currently employed by the Business Entity in a managerial, accounting, auditing, or similar capacity who were employed by the entity's fiscal intermediary or carrier within the previous 12 months? d. Have you verified through the System for Award Management (SAM.gov) that none of the employees and none of your Board of Directors or Governing Board and Managing Employees (General Manager, Business Manager, Administrator, Director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day to day operation) working in you practice(s) are excluded from participating in Medicaid or Medicare programs? te: remarks are needed if the answer to this question is "". 9/6/2014

9 Name of Entity: Page 2 Disclosure of Ownership and Control Interest Statement Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the Business Entity. A Business Entity is defined as a Medicare and/or Medicaid provider or supplier, or other entity that furnishes services or arranges for furnishing services under Medicaid and/or Medicare Program. Indirect ownership interest is defined as ownership interest in a Business Entity that has direct or indirect ownership interest in the disclosing entity with ownership of 5 percent or more. Controlling interest is defined as the operational direction or management of this Business Entity which may be maintained by any or all of the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity (i.e., joint venture agreement, unincorporated business status) of this Business Entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of this Business Entity; the ability or authority, expressed or reserved, to amend or change the by laws, constitution, or other operating or management direction of this Business Entity; the right to control any or all of the assets or other property of this Business Entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity, or to arrange for the sale or transfer of this Business Entity to new ownership or control. 3a. List names, addresses, and EIN for individuals or organizations having direct or indirect ownership or a controlling interest in this Business Entity. (List each member of the Board of Directors or Governing Board and Managing Employees also including General Manager, Business Manager, Administrator, Director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day to day operation.) List any additional names and addresses under "Remarks" on page 4. If more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks. Name Address EIN b. Type of Entity Sole Proprietorship Partnership Corporation Unincorporated Associations Other c. If this Business Entity is a corporation, list names, addresses of the Directors, and EINs for entities under Remarks. 9/6/2014

10 Name of Entity: Page 3 Disclosure of Ownership and Control Interest Statement Check appropriate box for each of the following questions: d. Are any owners of the Business Entity also owners of other Medicare/Medicaid facilities? (Example: sole proprietor, partnership or members of Board of Directors.) If yes, list names, addresses of individuals and provider numbers. Name Address Provider Number 4a. Has there been a change in ownership or control within the last year? If yes, give date b. Do you anticipate any change of ownership or control within the year? If yes, when? c. Do you anticipate filing for bankruptcy within the year? If yes, when? 5. Is this entity operated by a management company, or leased in whole or part by another organization? If yes, give date of change in operations 6. Has there been a change in management (such as: change in Director, a new Administartor, contracting operations of facility to a management coproration, hiring or dismissing employees with 5% or more interest, or similar change) within the last year? 7a. Is this entity chain affiliated? (If yes, list name, address of Corporation, and EIN) Name EIN# Address 9/6/2014

11 Name of Entity: Page 4 Disclosure of Ownership and Control Interest Statement 7b. If the answer to Question 7a. is, was the entity ever affiliated with a chain? (If yes, list Name, Address of Corporation, and EIN) Name EIN# Address WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION OF THIS STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR THE SECRETARY, AS APPROPRIATE. Name of Authorized Representative (Typed) Title Signature Date Remarks if applicable 9/6/2014

12 Commonwealth of Virginia Department of Medical Assistance Services Smiles for Children Program Participation Agreement If re-enrolling, enter NPI here This is to certify: PAYMENT/CORRESPONDENCE ADDRESS PHYSICAL ADDRESS (REQUIRED IF DIFFERENT FROM PAYMENT ADDRESS) INDIVIDUAL NAME ATTENTION ADDR LINE 1 ADDR LINE 2 CITY, STATE, ZIP on this day of, agrees to participate in the Smiles for Children Program, the Department of Medical Assistance Services (DMAS), the legally designated State Agency for the administration of Medicaid, FAMIS and FAMIS Plus. 1. The provider is authorized to practice under the laws of the state in which he is licensed and practicing and is not as a matter of state or federal law disqualified from participating in the Program. 2. Services will be provided without regard to age, sex, race, color, religion, national origin, or type of illness or condition. handicapped individual shall, solely by reason of his handicap, be excluded from participation in, be denied the benefits of, or be subjected to discrimination in (Section 504 of the Rehabilitation Act of l USC.794) DMAS. 3. The provider agrees to keep such records as DMAS determines necessary. The provider will furnish DMAS on request information regarding payments claimed for providing services under the State Plan. Access to records and facilities by authorized DMAS representatives and the Attorney General of Virginia or his authorized representatives, and federal personnel will be permitted upon reasonable request. 4. The provider agrees that charges submitted for services rendered will be based on the usual, customary, and reasonable concept and agrees that all requests for payment will comply in all respects with the policies of DMAS for the submission of claims. 5. Payment made by DMAS constitutes full payment except for patient pay amounts determined by DMAS, and the provider agrees not to submit additional charges to the recipient for services covered under DMAS. The collection or receipt of any money, gift, donation or other consideration from or on behalf of a medical assistance recipient for any service provided under medical assistance is expressly prohibited. 6. The provider agrees to pursue all other available third party payment sources prior to submitting a claim to DMAS. 7. Payment by DMAS at its established rates for the services involved shall constitute full payment for the services rendered. Should an audit by authorized state or federal officials result in disallowance of amounts previously paid to the provider by DMAS, the provider will reimburse DMAS upon demand. 8. The provider agrees to comply with all applicable state and federal laws, as well as administrative policies and procedures of DMAS as from time to time amended. 9. This agreement may be terminated at will on thirty days' written notice by either party or by DMAS when the provider is no longer eligible to participate in the Smiles for Children Program. 10. All disputes regarding provider reimbursement and/or termination of this agreement by DMAS for any reason shall be resolved through administrative proceedings conducted at the office of DMAS in Richmond, Virginia. These administrative proceedings and judicial review of such administrative proceedings shall be pursuant to the Virginia Administrative Process Act. 11. This agreement shall commence on. Your continued participation in the Smiles for Children Program is contingent upon the timely renewal of your license. Failure to renew your license through your licensing authority shall result in the termination of your Smiles for Children Participation Agreement. For Provider of Services: Original Signature of Provider Date Provider Specialty City OR County of Board License Number (Area Code) Telephone Number IRS Identification Number (Required) UPIN Medicare Carrier and Vendor Number Revised

13 AUTHORIZATION TO HONOR DIRECT AUTOMATED CLEARING HOUSE (ACH) CREDITS DISBURSED BY DENTAQUEST, LLC INSTRUCTIONS 1. Complete all parts of this form. 2. Execute all signatures where indicated. If account requires counter signatures, both signatures must appear on this form. 3. IMPORTANT: Attach voided check from checking account. 4. Send the completed form and voided check to DentaQuest Via Fax (262) Via E Mail StandardUpdates@dentaquest.com I will participate in Electronic Funds Transfer (EFT) of payments directly deposited into my account. (Complete all of the following information) t able to participate (Please complete the EFT Exemption Section) EFT Exemption (Check on of the below boxes) Unable to transact business through a banking institution capable of EFT Other reason for exemption consideration (if checked please submit supporting documentation) ACCOUNT HOLDER INFORMATION: 1. Routing Number: 2. Bank Account Number: Account Type: Checking Personal Business (choose one)

14 Bank Name: Account Holder Name: Effective Start Date: Legal Business/Entity Name: Tax ID Number As a convenience to me, for payment of services or goods due me, I hereby request and authorize DentaQuest, LLC to credit my bank account via Direct Deposit for the (agreed upon dollar amounts and dates.) I also agree to accept my remittance statements online and understand paper remittance statements will no longer be processed. This authorization will remain in effect until revoked by me in writing. I agree you shall be fully protected in honoring any such credit entry. I understand in endorsing or depositing this check that payment will be from Federal and State funds and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws. I agree that your treatment of each such credit entry, and your rights in respect to it, shall be the same as if it were signed by me. I fully agree that if any such credit entry be dishonored, whether with or without cause, you shall be under no liability whatsoever. Date Phone Number Print Name Signature of Depositor (s) (As shown on Bank records for the account, which this authorization applicable.) Legal Business/Entity Name (As appears on W 9 submitted to DentaQuest) Tax Id (As appears on W 9 submitted to DentaQuest

15 Please attach your VOIDED check here

16 Please attach your VOIDED check here Legal Business/Entity Name: Tax ID Number ACH Authorization 2 Current Dental Terminology 2013 American Dental Association. All rights reserved.

17 Form W-9 (Rev. January 2011) Department of the Treasury Internal Revenue Service Name (as shown on your income tax return) Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. Business name/disregarded entity name, if different from above Check appropriate box for federal tax classification (required): Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate Exempt payee Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Other (see instructions) Address (number, street, and apt. or suite no.) Requester s name and address (optional) City, state, and ZIP code List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the Name line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. te. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Social security number Employer identification number Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners share of effectively connected income. Date te. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: An individual who is a U.S. citizen or U.S. resident alien, A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, An estate (other than a foreign estate), or A domestic trust (as defined in Regulations section ). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat X Form W-9 (Rev )

18 Smiles for Children Program Administered by DENTAQUEST, LLC DENTAL PROVIDER SERVICE AGREEMENT THIS AGREEMENT, effective as of the date executed by DentaQuest, ("Effective Date"), is made between THE VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES, (hereinafter referred to as DMAS ) and DENTAQUEST, LLC (hereinafter referred to as DentaQuest") and (hereinafter referred to as "Provider"). (Entity Name as appears on W-9) On the Effective Date, this Agreement supersedes and replaces any existing agreements between the parties relating to the provision of dental services to Members. RECITALS WHEREAS, DentaQuest is a limited liability company qualified to do business in Virginia, which has as its primary objective the delivery of dental services to Members of the Smiles For Children program, operated under the direction of DMAS; WHEREAS, Provider, has an unrestricted license to practice dentistry in the Commonwealth of Virginia and desires to provide dental services pursuant to the terms and conditions of this Agreement; WHEREAS, DMAS, DentaQuest and Provider desire to enter into this agreement in order to facilitate streamlined administration of the agreement and to comply with requirements of federal and state law; NOW, THEREFORE, in consideration of the above and the promises hereinafter contained, the parties hereby agree as follows: 1. DEFINITIONS As used in this Agreement, the following terms shall have the following respective meanings. All other capitalized terms used herein but not defined shall have the meanings set forth in the Agreement. (a) Agreement : This Agreement between DentaQuest acting on behalf of the Smiles For Children program and Provider, including all attachments hereto. (b) Appeal Procedure : The process whereby a Provider exercises their right to contest verbally or in writing any adverse action taken by DentaQuest to deny, reduce, terminate, delay or suspend a Covered Service. (c) Covered Service : A dental health care service or supply, including those services covered through the Early and Periodic, Screening, Diagnosis, and Treatment (EPSDT) program that satisfies all of the following criteria: (1) is medically necessary; (2) is covered under the Smiles For Children program ; (3) is provided to an enrolled Member by a Participating Provider; and (4) is the most appropriate supply or level of care that is consistent with professionally recognized standards of dental practice within the service area and applicable policies and procedures. (d) DMAS : The Virginia Department of Medical Assistance Services. (e) Emergency Services : Covered dental services furnished by a qualified provider that are needed to evaluate or stabilize an emergency medical condition that is found to exist using the prudent layperson standard Smiles For Children 1 Current Dental Terminology 2013 American Dental Association. All rights reserved.

19 IN WITNESS WHEREOF, the parties hereto have executed this Smiles for Children Provider Agreement on the date written below: Provider/Clinic Name & Address DENTAQUEST, LLC Name Address Phone Tax ID Group NPI #: BY: (Signature) BY: Steve Pollock Chief Operating Officer BY: (Please Print or Type Name) DATE: / / DATE: / / PROVIDER DENTISTS (Please Type or Print) Please list the name of all individual dentists providing services under the terms of this Agreement. Dentist Name Dentist Name Dentist Name Dentist Name Specialty Specialty Specialty Specialty Smiles For Children 11 Current Dental Terminology 2013 American Dental Association. All rights reserved.