Please list locations where provider regularly sees patients.
Primary Practice:
Medicare numbers are not currently required for UPMC Dental Advantage applicants to accept our Medicare product.
Secondary Practice:
Medicare numbers are not currently required for UPMC Dental Advantage applicants to accept our Medicare product.
Additional Practice:
Medicare numbers are not currently required for UPMC Dental Advantage applicants to accept our Medicare product.
Additional Practice:
Medicare numbers are not currently required for UPMC Dental Advantage applicants to accept our Medicare product.
Providers that utilize CAQH may enter their CAQH provider ID in the space below. After review of the participation request submitted, UPMC Health Plan will retrieve the provider’s CAQH application for credentialing.
CRNPs, CNMs, and PAs: Please attach a copy of the collaborative agreement to the CAQH application documentation.
Oral surgery providers will need to complete credentialing with UPMC Health Plan for Medical and SKYGEN/UPMC Health Plan Dental Advantage for routine dental products.
By submitting this request for participation, I hereby attest that all of the information I am about to submit is true and accurate to the best of my knowledge.
I understand that any information provided pursuant to this attestation that is subsequently found to be untrue and/or incorrect
could result in my termination from UPMC Health Plan should I be approved.