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Welcome to GOLDEN WEST

Provider Maintenance Form

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.

Contact Information:

Email: contractintake@decare.com

Fax: 877-329-6459

Mail:

P.O. Box 640

Minneapolis, MN 55440-0640

Reason for Submitting this Form

Option 1 - Provider Level Changes
  • Remove a provider from a location
  • Name change for individual dental practitioner
  • License number change for individual dental practitioner
  • Add or change provider's degree
  • Update or add your Individual NPI
  • Add or change provider's language(s) spoken (other than English)
  • Add or change your provider specialty or type
Please note: Specialty changes may require additional follow-up if not already approved by credentialing.
CLICK HERE to make one or more of the above changes.
Option 2
    Practice changes (these changes apply to all providers currently practicing under the Tax Identification (TIN) provided).

    Note: If additional information is required you will be contacted by a Network Representative.
  • Change your Tax Identification Number/IRS Name (TIN)
  • Change in ownership for an existing practice
  • Change your practice address or phone/fax number
  • Change your practice name
  • Add a new location
  • Close a practice location
  • Change your billing or correspondence address
  • Change your office hours or days of operation
  • Change in your acceptance of new patients
  • Update or add your Organizational Clinic or Corporate NPI
  • Update or add your email address(es)
  • Add or change language(s) spoken by qualified medical interpreter
CLICK HERE to make one or more of the above changes.