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 Dental Care Alliance (DCA) - Office Enrollment Form

PLEASE COMPLETE THE FORM BELOW TO ENROLL YOUR PRACTICE

  • We will also send you a Business Associates Agreement (BAA) to be completed before activation.

  • When the Office Enrollment & BAA have been received, we will send you a welcome packet to be emailed within 2-3 days.

  • Next, we will plan your onboarding:

    • Training #1 - Pristine Medical Billing Model: We will educate you on how to create your fee schedule for medical insurances.

    • Training #2 - We will educate you on what documentation is needed from your team to appropriately bill medical insurances.

Please call (844) 597-7617 or email info@PristineMedicalBilling.com if you need any assistance with the following form.

Address *
Address
Practice Phone *
Practice Phone
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