Enrollment Form

Are you brand new to Pristine, or updating/adding to past information?

Legal Entity Name

Practice Name/DBA

Practice Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you plan on servicing out of multiple locations? (ie delivering appliances in different offices)

Yes

If yes, please list the addresses for those locations here:

**ALSO LIST THE TAX ID #'S IF THEY'RE DIFFERENT PER LOCATION**

If you would like payments from the insurance sent to a different address, please list that address here:

Practice Phone

(###)

###

####

Fax

(###)

###

####

Website

http://

Are you billing under a separate sleep practice (different than dental)? If so, please list the corresponding Tax ID and NPIs below.

Tax ID Number

Group/Entity NPI Number

Office Contact Name

First Name

Last Name

Office Contact Email

Doctor's Personal Email

Primary Doctor Name

First Name

Last Name

Primary Doctor Email

Primary Doctor Individual NPI Number

Primary Doctor DOB

Skip the next 2 sections if there is only one Doctor at your location.

2nd - Doctor Name (if applicable)

First Name

Last Name

2nd - Doctor Email (if applicable)

2nd - Doctor Individual NPI Number (if applicable)

2nd - DOB

Skip the next section if there are only 2 Doctors at your location.

3rd - Doctor Name (if applicable)

First Name

Last Name

3rd - Doctor Email (if applicable)

3rd - Doctor Individual NPI Number (if applicable)

3rd - DOB

Is your practice a Medicare DME supplier for Oral Appliance Therapy?

YES - I am a Non-Participating Medicare DME Supplier (medicare reimburses our patients directly)

YES - I am a Participating Medicare DME Supplier (medicare reimburses our practice directly)

NO - I am Not a Medicare DME Supplier

Medicare PTAN Number

Are you a registered Tri-care provider?

Yes

Please list any insurance companies that you are currently contracted with for MEDICAL:

Please list any MEDICAL insurance companies that you have billed in the past under the Tax ID and NPIs listed above:

Please list any insurance companies that you are currently contracted with for DENTAL:

CAQH ID

Required for Credentialing - Link: https://proview.caqh.org/Login