Provider Enrollment Form

	Provider Information
Provider Name:
Business Name:
Street Address
City:
State:
Zip:
Telephone:
email address:
Business Website:

	Provider Type (Please select one preference)
Preferred Provider	As such, our office will bill all PDN Members based on the PDN Fee Schedule, with we have received and reviewd. The Feed Schedule has been approved by the above provider.
Associate Provider	We agree to extent to all PDN Members who present a PDN Membership Card the following discounts off our regular/usual fees for Dental Services. General Members (under 62): 20% off minor procedures and 30% off major procedures Senior Members (62 and over): 25% off minor procedures and 35% off major procedures
Associate Provider	We agree to extent to all PDN Members who present a PDN Membership Card the following discounts off our regular/usual fees for Dental Services. General Members (under 62): % off minor procedures and % off major procedures Senior Members (62 and over): % off minor procedures and % off major procedures

	Plan Participation
	We agree that in the event we no longer wish to participate as a PDN provider, we will notify PDN in writing. We agree to continue accepting PDN members and honor the above stated discounts, for ninety (90) days from the date of such notice and complete all work in progress at the rate agreed upon on this form.

Phone: 315-698-9800 / 800-270-2226 FAX: 315-698-9807

For more information please email info@ progressivedentalnetwork.com