BILLING STATEMENT AND SUMMARY OF BENEFITS

*required

Practice Information:

PRACTICE NAME*

PRACTICE STATE*

—Please choose an option—ALAKAZARCACOCTDCDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

NAME OF A PRIMARY DENTIST*

COOPERATIVE ACCOUNT# (If Dental Cooperative Member. Found on Invoice. Optional)

Monthly Billing Statement

In an effort to save waste and go paperless, the Dental Cooperative now sends monthly billing statements out only upon request. The monthly billing statement reflects your Cooperative membership fees for the month. Since this is already reflected on your credit card or bank statement, most Members consider this statement unnecessary. If you would like to receive a monthly billing statement, we are happy to do that for you. Please complete the following information:

CHECK THE BOX TO RECEIVE A MONTHLY BILLING STATEMENT

Monthly Billing Statement

[group YesMonthlyBillingStatement clear_on_hide]
HOW WOULD YOU LIKE TO RECEIVE YOUR MONTHLY BILLING STATEMENT:

—Please choose an option—Email OnlyEmail and Mail

TO WHOM SHOULD WE SEND YOUR MONTHLY BILLING STATEMENT?

You may choose up to 2 contacts.

Contact #1:
FIRST AND LAST NAME*

JOB TITLE

—Please choose an option—DentistOffice ManagerAccountantOther

EMAIL*

Contact #2:
FIRST AND LAST NAME*

JOB TITLE

—Please choose an option—DentistOffice ManagerAccountantOther

EMAIL*

[/group]

Summary of Benefits

As with the billing statement, in an effort to save waste and go paperless, the Dental Cooperative now sends Summary of Benefit out quarterly.The Summary of Benefits is a snapshot of the Cooperative programs your practice is currently using and programs available to use. Keep in mind that you can request your current Summary of Benefits anytime from your Area Director. The Dental Cooperative automatically send out your Summary of Benefits every quarter in February, May, August, and November. If you would like to receive your Summary of Benefits monthly, please check the box below:

CHECK THE BOX TO RECEIVE A MONTHLY SUMMARY OF BENEFITS

Monthly Summary of Benefits

[group YesMonthlySummary clear_on_hide]
HOW WOULD YOU LIKE TO RECEIVE YOUR MONTHLY SUMMARY OF BENEFITS:

—Please choose an option—Email OnlyEmail and Mail[/group]

TO WHOM SHOULD WE SEND YOUR SUMMARY OF BENEFTIS

You may choose up to 2 contacts.

Contact #1:
FIRST AND LAST NAME*

JOB TITLE

—Please choose an option—DentistOffice ManagerAccountantOther

EMAIL*

Contact #2:
FIRST AND LAST NAME*

JOB TITLE

—Please choose an option—DentistOffice ManagerAccountantOther

EMAIL*

[group PrimaryMailingAddress clear_on_hide]
PLEASE CONFIRM YOUR PRIMARY MAILING ADDRESS

NOTES OR REQUESTS

Once submitted, we will make the changes in our database. If you would like to change your preferences, you can contact your Area Director anytime to make the changes.