The Provider Maintenance Form (PMF) is to be used by dental practitioners to request changes to their practice profiles.
It is critical that our members receive accurate and current data related to provider availability. Changes to provider records that are affiliated with group contracts must be reported to and submitted by the practice manager or other designated person of authority at the group. Changes to individual contracts may be made at the direction of the contracted dental practitioner. All requests must be received 30 days prior to the change/update. Submit the PMF to notify of any changes to the provider/practice name, practice/mailing address, tax identification number, phone and fax numbers, practice office hours, provider leaving/retiring, provider joining the practice, practice accepting new patients, handicapped accessibility, specialties or languages offered.
Please follow these instructions when submitting the PMF:
Complete all applicable sections. This form has multiple options (+) for changes. Complete only the sections applicable to the requested change(s). NOTE: This form will time out after 30 minutes of activity or inactivity and all entries made but not yet submitted will be lost.
Please note: A Network Representative will contact you if your change requires a W-9, or any additional documentation is required to complete the update.
P.O. Box 640
Minneapolis, MN 55440-0640