Dental Care Alliance (DCA) - Office Enrollment Form

Please complete the form below to EnroLl your practice

You will also receive a Business Associates Agreement (BAA) to be completed before your account activation.
Once the Office Enrollment & BAA have been received we will activate your account within 1 business day.
Finally, expect contact from your Account Manager & Dental Sleep Coach to plan your orientation webinar.

Please contact Customer Service at 630-845-3483 or email Info@SleepTest.com if you need any assistance with the following form.

Practice Name *

Group Practice Name

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Username to SleepTest.com Portal *

1 Email Address for Patient Status Notifications *

2 Email Address for Patient Status Notifications

3 Email Address for Patient Status Notifications

Preferred Office Contact/Sleep Coordinator Name *

Practice Phone *

Practice Phone

(###)

###

####

Back Office Phone

(###)

###

####

Website

http://

Number of Doctors Enrolling to Refer Patients from your Practice (Must complete additional referring doctor info below.) *

Group NPI Number

Tax ID Number *

Primary Doctor Name *

Primary Doctor Name

First Name

Last Name

Primary Doctor Email Address *

Individual NPI Number *

State License Number *

Skip the rest of the sections if there is only one Doctor at your location.

2nd - Doctor Name (if applicable)

First Name

Last Name

2nd - Doctor Email Address (if applicable)

2nd Doctor - Individual NPI Number (if applicable)

2nd Doctor - State License Number (if applicable)

Skip the rest of the sections if there are only 2 Doctors at your location.

3rd - Doctor Name (if applicable)

First Name

Last Name

3rd - Doctor Email Address (if applicable)

3rd - Doctor - Individual NPI Number (if applicable)

3rd - Doctor - State License Number (if applicable)

Skip the rest of the sections if there are only 3 Doctors at your location.

4th - Doctor Name (if applicable)

First Name

Last Name

4th - Doctor Email Address (if applicable)

4th - Doctor - Individual NPI Number (if applicable)

4th - Doctor - State License Number (if applicable)

Skip the rest of the sections if there are only 4 Doctors at your location.

5th - Doctor Name (if applicable)

First Name

Last Name

5th - Doctor Email Address (if applicable)

5th - Doctor - Individual NPI Number (if applicable)

5th - Doctor - State License Number (if applicable)

Dental Care Alliance (DCA) - Office Enrollment Form

Please complete the form below to EnroLl your practice

info@SleepTest.com |1-800-SLEEPTEST | www.SleepTest.com

425 Quadrangle Dr. #130 Bolingbrook, IL 60440