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Type of Update Requested:
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| New Tax ID#: |
*
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| Reason for Updated Tax ID#: |
*
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New Associate Name:
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*
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New Associate Tax ID#:
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*
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Location(s) of New Associate:
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Please either check "All Locations" or list the locations affected by the new associate.
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| Location Address to Delete: |
*
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| New Location Address: |
*
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| New Account Type: |
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| New Account Number: |
(Re-Enter)
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| New Routing And Transit Number: |
*
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| New Financial Institution Name: |
*
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Name of Dentist:
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*
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Reason for Leaving:
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*
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Location(s) Affected:
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Please either check "All Locations" or list the locations affected by the dentist leaving.
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| Tax ID#: |
*
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| Phone (Current): |
*
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| Phone (Updated To): |
*
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| Fax (Current): |
*
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| Fax (Updated To): |
*
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| Email (Current): |
*
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| Email (Updated To): |
*
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| Requested Update Effective Date: |
*
*
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| Submitted By: |
*
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| Email: |
*
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Practice Name:
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*
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Practice Address:
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*
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Practice Phone #:
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Practice Fax #:
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By entering my initials in the box below, I certify that I am authorized to make the requested change on behalf of the company identified on this form.
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NOTE: Please use our Document Upload to securely send the following documents for proper processing: W-9 - required for new location, new associate or tax id update
Voided Check - required for Banking Update.
*If new associate is not currently credentialed with Superior Dental Care, full application and contracts will also be required.
These documents may be found on our website or you may request full application packet by mail or email by contacting Dentist Enrollment at 800-762-3159
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