PRACTICE NAME: (Current Location) Address: City: State: Zip: Month / Year Current From Dates: / to PRACTICE NAME: Address: City: State: Zip: Month / Year Month / Year From Dates: / to / PRACTICE NAME: Address: City: State: Zip: Month / Year Month / Year From Dates: / to / PRACTICE NAME: Address: City: State: Zip: Month / Year Month / Year From Dates: / to / PRACTICE NAME: Address: City: State: Zip: Month / Year Month / Year From Dates: / to / Alternative Languages Spoken: LIBERTY Dental Plan Questions: Do you provide all services as outlined in the schedule of benefits? Yes No If No, please explain: 2. Do you participate in any other DHMO or PPO Programs (please list) Yes No 3. Would you be interested in serving on a Peer Review Panel or Quality Assurance Committee? Professional Questions and Attestation: (All questions must be answered) please include a detailed explanation with this form. For each “YES” response If a please each response. question is “Not Applicable,” mark “NO” for
PRACTICE NAME: (Current Location) Address: City: State: Zip: Month / Year From Dates: / to Current PRACTICE NAME: Address: City: State: Zip: Month / Year Month / Year From Dates: / to / PRACTICE NAME: Address: City: State: Zip: Month / Year Month / Year From Dates: / to / PRACTICE NAME: Address: City: State: Zip: Month / Year Month / Year From Dates: / to / PRACTICE NAME: Address: City: State: Zip: Month / Year Month / Year From Dates: / to / Alternative Languages Spoken: LIBERTY Dental Plan Questions: Do you provide all services as outlined in the schedule of benefits? Yes No If No, please explain: 2. Do you participate in any other DHMO or PPO Programs (please list) 3. Would you be interested in serving on a Peer Review Panel or Quality Assurance Committee? Yes No Professional Questions and Attestation: (All questions must be answered) For each “YES” response please include a detailed explanation with this form. If a question is “Not Applicable,” please mark “NO” for each response.