MARYLAND UNIFORM CREDENTIALING FORM

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					          MARYLAND UNIFORM CREDENTIALING DENTAL FORM

What is the Maryland Uniform Credentialing Form and who is required to use it?
Effective January 1, 2008, a new Maryland Uniform Credentialing Dental Form (UCF)
was adopted by the Insurance Commissioner to replace the UCF Form in use since 1999.
Regulations were modified and amended to delete the old Form and adopt the new Form.
Dental plan organizations shall use the Maryland Uniform Dental Credentialing Form as
the sole application for providers of dental care services to become credentialed or
recredentialed for participation on their dental care provider panels. The regulations apply
to all carriers and their credentialing intermediaries without exception. The old UCF may
no longer be used when credentialing or recredentialing health care providers for
participation on a carrier’s provider panel in Maryland.

PLEASE SUBMIT THE FOLLOWING:

1) A copy of all state professional licenses from each state in which you are currently
licensed to practice.

2) A copy of your current state narcotics or state controlled dangerous substance (CDS)
certificate, if held.

3) A copy of your current DEA certificate, (State specific) if held

4) A copy of your ECFMG certificate, if held.

5) A copy of your Board Certification Certificate, if held.

6) A copy of your current professional liability insurance certificate or declaration page
(face sheet) of your insurance policy. The document should include the name of the
company, name of applicant, policy number, dates of coverage and amounts of coverage,
(State specific).

7) W-9 Tax Identification Form

8) Copies of any other certifications held.


DentaQuest –Provider Relations Department
4061 Powder Mill Road, Ste 325
Calverton, MD 20705
301-937-4447 ext 3040
Tollfree 1-800-879-0288 ext 3040
Fax. 301-937-2957 or 301-937-0245
www.dentaquestdental.com
(Rev: 1/1/2008)


				
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