Provider Forms

• Healthplex Provider Web Portal Guide
• ADA Attestation
• Credentialing Package - Dentist Personal Profile
• ADA Claim Form
• Healthplex Provider Manual
• W-9/Office Information Form
• Provider Authorization Agreement For Direct Deposit Form
• EmblemHealth Quick Reference Guide
• Connecticare Quick Reference Guide

Orthodontic Templates

• Orthodontic Form Interceptive
• Dismissal Letter
• Braces Removal and Retainer Consent Form
• Orthodontic Treatment Progress
• Consent Form
• Release From Treatment - Provider
• Release From Treatment - Patient Request
• Dental Clearance Note