Mission

	Provider Forms and Materials

ACCESS DENTAL PROVIDERS

General

Associate Application
Practice & Facility Information
Form W-9: Request for TIN and Certification
Provider Dispute Resolution Mechanism
Specialist Referral Form
Claim/Encounter Form
Provider Manual

Member Grievance Forms

Grievance Form - English
Grievance Form - Spanish
Grievance Form - Chinese
Grievance Form - Vietnamese
Grievance Form - Russian

PREMIER ACCESS PROVIDERS

General

Associate Application
Practice & Facility Information
Form W-9: Request for TIN and Certification
Provider Dispute Resolution Mechanism
Claim Form

Specialist Referral Form

Healthy Families Program, Healthy Kids Santa Barbara
Utah CHIP

Provider Manual / Dentist Handbook / Reference Guide

Commercial PPO
Healthy Families Program, Healthy Kids Santa Barbara
Utah CHIP Quick Reference Guide
Utah CHIP Procedure Guidelines – General Dentist
Utah CHIP Procedure Guidelines – Pedodontists
Utah CHIP Procedure Guidelines – Specialists

Member Grievance Forms

Grievance Form - English
Grievance Form - Spanish

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