442 SW Umatilla Ave., Ste. 200, Redmond, OR FMA v

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1 Thank you for letting us know that there is an associate working in your office. Enclosed is the Associate Agreement for participation as a provider for the plan(s) you are contracted with through Advantage Dental. Also, enclosed is an Associate Provider Application. Please have these forms completed, signed, and mailed, ed, or faxed back to Advantage Dental. Also include the malpractice insurance binder page for your associate. Prompt attention to this matter world be greatly appreciated so that claims may be processed properly. If you have questions, please feel free to contact us at or by at providerrelations@advantagedental.com Sincerely, Advantage Dental Provider Relations Department Enlosures Application for Associate Dental Provider Associate Provider Agreement SW Umatilla Ave., Ste. 200, Redmond, OR 97756

2 PERSONAL INFORMATION Name (Last, First, Middle Initial) Date (MM/DD/YY) Home Address (Street, City, State, Zip-Code) Specialty Sub-Specialty Home Phone Cell Phone Degree Date of Birth Birth Place (City, State) NPI Number SSN Medicare Provider Number DMAP Number License Number & State DEA Number Malpractice Carrier Policy Number CLINICAL PRACTICE Practice Name ATTENTION: Please Attach a copy of insurance binder/coverage page Street Address (Street, City, State, Zip-Code) Maililng Address (Street, City, State, Zip-Code) Make Checks Payable To (Name, City, State, Zip-Code) Tax ID Number Organization NPI Number Handicap Access? YES NO Business Phone Business Fax County ADDITIONAL PRACTICE INFORMATION Practice Name Street Address (Street, City, State, Zip-Code) Maililng Address (Street, City, State, Zip-Code) Make Checks Payable To (Name, City, State, Zip-Code) Tax ID Number Organization NPI Number Handicap Access? YES NO Business Phone Business Fax County

3 I,, am an employee of. Associate Name and Credential(s) Dental Contractor I agree to abide by the terms of the dental provider agreement between Dental Contractor and Advantage Dental Plan, Inc. and/or Advantage Dental Services, LLC. ASSOCIATE DENTAL CONTRACTOR Thomas S. Tucker, DMD Advantage Dental Plan, Inc Advantage Dental Services, LLC CEO Effective

4 Certificate Holder Request TO: (Insurance Agent) Fax: (Agent Fax) From: (Office Name) (Doctor Name) Please Add Advantage Dental as a certificate holder on my Professional Liability Policy Advantage Professional Management, LLC 442 SW Umatilla Ave. Redmond, OR f) Thank you for your prompt attention to this matter. Sincerely, Provider Relations

5 Release of Information I,, DDS/DMD, grant to Advantage Professional Management, LLC and its employees and authorized agents authority and permission to obtain, inspect, and duplicate any and all information, including without limitation records, summaries of records, statistical reports, malpractice claim information, and utilization profiles pertinent to my provision of dental services or my dental professional qualifications currently on file at any and all health care facilities, health maintenance organizations, insurance companies, dental trade associations, accrediting organizations, dental societies, individual practice associations, governmental entities, educational and training institutions, or any other institutional settings with which I am now affiliated or have been affiliated. The information required by this paragraph shall be referred to as the information. I represent and warrant that all information I provide in support of my credentialing is and will be complete, up to date, and accurate. I waive and release any and all claims against individuals or entities providing the information and agree to execute any additional written authorization or release that may be required to obtain the information. A photocopy of this Release of Information shall be effective as an original. I waive and release, and agree to indemnify, Advantage Professional Management, LLC, its employees, and agents from any and all claims, liability, costs, and expenses arising out of or related to the release of the information or information required by the Dental Provider Application to any purchaser of health or dental care services or to any governmental agencies. I understand that Advantage Professional Management, LLC will not complete the application process until Advantage Professional Management, LLC is satisfied that it has obtained sufficient information to fully and fairly evaluate the application. I understand and acknowledge that I bear the final responsibility for ensuring that all information and documentation required for credentialing is delivered or otherwise obtained in a timely manner. (A stamped signature is not acceptable), DDS/DMD (Print Full Name) (Social Security Number)