• Need Insurance?
  • Already a Member
  • For Employers
  • For Brokers
  • For Providers
    • Home
    • Join Our Networks

      • Professional

      • Credentialing Overview
      • How to Apply
      • CAQH Universal Credentialing
      • Credentialing FAQs
      • Find a Provider Rep

      • Institutional/Ancillary

      • Credentialing Overview
      • How to Apply
      • Credentialing Forms
      • Credentialing FAQs
      • Find a Provider Rep

      • Dental

      • Credentialing Overview
      • How to Apply
      • CAQH Universal Credentialing
      • Credentialing Forms
      • Credentialing FAQs
      • Find a Provider Rep
    • Programs/Services

      • Medical

      • Electronic Capabilities
      • Medical Policy
      • Pre-Cert/Pre-Auth (In-Network)
      • Pre-Cert/Pre-Auth (Out-of-Area)
      • Medical Forms
      • Medical News

      • Dental

      • Dental Overview
      • Dental Electronic Capabilities
      • Dental NPI & Payer Codes
      • Dental Clinical Criteria
      • Dental Forms
      • Dental News
      • Dental Seminar Video
      • Dental Wellness

      • Pharmacy

      • Pharmacy Exception Requests
      • Pharmacy Resources
      • Pharmacy Prior Authorization

      • Care Management

      • PCMH
      • PCMH News
      • Quality & Affordability
      • Clinical Resources

      • Wellness/Incentives

      • Blue Rewards
    • Resources

      • Administrative

      • CareFirst Direct
      • Update Practice Info
      • Manuals & Guides
      • Forms
      • Inquiries & Appeals
      • MD EHR Adoption Incentive

      • Claims

      • Claims Submission
      • Dental Claims Submission
      • NPI
      • Dental NPI & Payer Codes
      • Ancillary Claims
      • Corrected Claims
      • Medicare Secondary
      • Paper Claims

      • Resources

      • Find a Provider Rep
      • User Guides

      • News/Training

      • The Center for Provider Education & Training
      • Newsletters
      • News Archives
    Login
    Providers Login
    Provider Portal Maintenance

    iCentric/PCMH, Prior-Authorizations, and CareFirst Direct applications will not be available Saturday, September 22, 2018 from 5 PM to 11 PM

    User ID:
    Password:
    ?
    Need Help Logging In
    Create An Account
    Reset PasswordForgot User ID
    Guest Access

    Dental

    • Credentialing Overview
    • How to Apply
    • CAQH Universal Credentialing
    • Credentialing Forms
    • Credentialing FAQs
    • Find a Provider Rep
    PDF icon

    Viewing and printing this document requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

    Credentialing Forms

    Dental Credentialing

    Dental Billing Authorization Form
    Dental Practice Questionnaire
    Dental Provider Application
    Dental Provider Application Instructions
    Required Documents for Dental Credentialing
    • About Us
      • Company Overview
      • Signature Programs
      • Our History
      • Corporate Offices & Locations
      • Service Area
      • Annual Reports
      • Media Releases
    • Legal & Mandates
      • Patient Rights & Responsibilities
      • HIPAA
      • Health Care Fraud Prevention
      • Quality Improvement
      • Mental Health Parity
      • Machine Readable Data
    • Other Information
      • Community
      • Health Insurance Glossary
      • Contact Us
      • Send Us Your Feedback
    Facebook Twitter YouTube LinkedIn Instagram

    Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (Used in VA By: First Care, Inc.). First Care, Inc., CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.

    CareFirst of Maryland, Inc. and The Dental Network underwrite products in Maryland only.