Dental Forms

• Participating Dental Provider Application (PDF)
  This form is used to apply for participation on our dental network. Complete and sign the form, attach required documentation, and mail the application to:
  P.O. Box 21267 M/S S704
  Seattle, WA 98111-3267
• Provider Information Change Request (PDF)
  Use this form to report and changes or additions to the provider’s demographics or tax ID. A signature is required before the changes can take effect. If the tax ID is changing, you must submit a W-9 form. If the address is changing, you will need to include proof of insurance for that location.