Connection Dental Network – Provider Application (GEHA Connection Dental Network) and Participating Provider Agreement Instructions
This form contains 14 fields organized into 7 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| GEHA/Connection Representative Signature | ||
| Signature Date (GEHA/Connection) | Date |
Enter the date on which the GEHA/Connection representative signed this agreement.
|
| Representative Signature (GEHA/Connection) | Text |
Enter the signature or printed name of the GEHA/Connection representative who executed this agreement.
|
| General | ||
| Signature4 | Signature | |
| Participating Provider Address | ||
| Primary Practice Street Address | Text |
Enter the provider's primary practice street address (street number and name, suite or unit if applicable).
|
| Primary Practice City / State / ZIP | Text |
Enter the city, state and ZIP code for the provider's primary practice (and any additional address lines such as building or attention line if needed).
|
| Participating Provider Contact | ||
| Participating Provider Phone | Text |
Enter the provider's primary contact phone number for the participating provider (include area code and any extension if applicable).
|
| Participating Provider Email | Text |
Enter the provider's primary email address for contact regarding this agreement.
|
| Participating Provider Fax | Text |
Enter the provider's fax number for this practice (include area code).
|
| Participating Provider Details | ||
| Printed Name of Participating Provider | Text |
Enter the provider's full printed name exactly as it should appear on the agreement.
|
| License State | Text |
Enter the U.S. state where the provider's license was issued (use the standard 2-letter postal abbreviation or full state name).
|
| Tax Identification Number (TIN) | Number |
Enter the provider's federal Tax Identification Number (TIN) used for billing and tax reporting.
|
| Professional License Number | Text |
Enter the provider's professional license number as issued by the state licensing board.
|
| Participating Provider Name | ||
| Participating Provider Name | Text |
Enter the full legal name of the participating provider (individual practitioner or practice/organization) that is entering into this agreement.
|
| Participating Provider Signature Date | ||
| Participating Provider Signature Date | Date |
Enter the date when the participating provider signed the agreement.
|