Connection Dental Network – Provider Application (GEHA Connection Dental Network) and Participating Provider Agreement Completed Form Examples and Samples
Explore a complete, filled-out example of the GEHA Connection Dental Network Provider Application and Participating Provider Agreement. Our detailed sample guides dental practitioners through each section, ensuring accuracy and simplifying the credentialing process. Use this resource to confidently complete your own GEHA dental provider application form.
GEHA Connection Dental Network Provider Application Example
How this form was filled:
This is an example of a completed Connection Dental Network Provider Application for a solo dental practitioner, Dr. Emily Carter, seeking to join the GEHA network. It demonstrates how to accurately fill out practitioner details, practice information, NPI and TIN numbers, malpractice insurance, and the W-9 and Participating Provider Agreement sections.
Information used to fill out the document:
- Practitioner's Name: Dr. Emily Carter, DDS
- Practice Name: Bright Smiles Dental Clinic
- Practice Type: Solo Practice
- Practice Address: 456 Innovation Drive, Suite 100, Austin, TX 78701
- Practice Phone: 512-555-0182
- Practice Fax: 512-555-0183
- Practice Email: [email protected]
- Billing Address: Same as Practice Address
- National Provider Identifier (NPI): 1234567890
- Tax Identification Number (TIN/EIN): 98-7654321
- Texas State License Number: TX-D23456
- License Original Issue Date: 06/15/2018
- Dental School: University of Texas Health Science Center at San Antonio
- Graduation Date: 05/20/2018
- Malpractice Insurance Carrier: Dentist's Professional Liability Co.
- Policy Number: DPL-987654321
- Policy Effective Date: 01/01/2026
- Policy Expiration Date: 12/31/2026
- Coverage Amount: $1,000,000 / $3,000,000
- Signature: Emily Carter, DDS
- Date Signed: 01/15/2026
What this filled form sample shows:
- Accurate completion of Practitioner and Practice Information sections for a solo practitioner.
- Correct inclusion of essential identifiers like NPI, Tax ID (TIN), and State License Number.
- Properly detailed Professional Liability (Malpractice) Insurance information.
- Completed IRS Form W-9 details integrated into the application.
- Signed and dated Participating Provider Agreement section to finalize the submission.
Form specifications and details:
| Use Case: | Solo Dental Practitioner Application for Network Participation |
| Form Name: | Connection Dental Network – Provider Application and Participating Provider Agreement |
| Network: | GEHA Connection Dental Network |
Created: February 10, 2026 05:59 PM
