| 1. |
Download the Dental Provider Enrollment Form:
 Dental Provider Enrolment Form
Sample Copy of a completed Dental Provider Enrollment Form:
Dental Provider Enrolment Form (Completed Sample)
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| 2. |
Complete the Dental Provider Enrollment Form fully for all required sections. |
| | Did you know… |
| | Electronic Funds Transfer (EFT) is free and secure! |
| | Sign up by completing the Payment Information section of the Dental Provider Enrollment Form and eliminate mail delivery delays of lost, misplaced, or stolen cheques! Receive your claim payments directly into your designated bank account on the day the payment is issued and still continue to receive mailed statements for reconciliation! |
| | Electronic Data Interchange (EDI) is a point of service, claim submission method to submit Dental claims electronically in real time! |
| | Purchasing a software compliant with CDAnet Electronic Claim Standard, Denturists Association of Canada (DACnet) or Réseau ACDQ (Association des chirurgiens dentistes du Québec) will expedite your claim submissions. Why not consider it today! For more information, contact your association to be advised of the list of certified software vendors. |
| 3. |
Sign the Dental Provider Enrollment Form (where indicated). |
| 4. |
Fax all pages (including a photo copy of a VOID cheque or official bank letter for EFT payments) of the Dental Provider Enrollment Form to Express Scripts Canada at fax number 905-712-0669.
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