Connection Dental - Applications/Documents

Thank you for your interest in joining the CONNECTION Dental Network. In order to apply to be in the network, you must complete and sign both an Application and a Participating Provider Agreement, and submit any requested supporting documentation.

To view a CONNECTION Dental Network Application or Attestation, you need the Acrobat Reader program. If you do not have Acrobat Reader, please click on the link provided below. The link will take you to the Acrobat Reader website and allow you to download Acrobat Reader free of charge.

Download Adobe Acrobat Reader

CONNECTION Dental Network Application / Fillable CONNECTION Dental Network Application
This Application is to be used by all individual dentists unless a different form is required by your State's laws. Click to download a copy of the Application.

CONNECTION Dental Network Attestation / Fillable CONNECTION Dental Network Attestation
This Attestation is to be used if you have already completed your Application, but it hasn't been signed by you recently. Click to download a copy of the Attestation.

State Mandated Credentialing Applications
If you are in a state that uses mandated credentialing forms, your state is requiring you to use their form. Click below to link to your State Mandated Application.

Participating Provider Agreement
You must complete the first paragraph and the entire signature block of the Agreement. You should retain a copy of the Agreement and Fee Schedule for your records. Click here to request a Participating Provider Agreement or call us at (800) 505-8880, Option 1.