Disclosure Of Ownership Form

DentaQuest is required by CMS (Centers for Medicare and Medicaid Services) to have a current Disclosure of Ownership and Conflict of Interest Form on file for every business participating in our Medicare and Medicaid networks. DentaQuest has posted additional documents below to assist businesses in the completion of this form.

A fillable PDF version of the Disclosure of Ownership and Conflict of Interest Form can be completed and signed electronically using Adobe Sign, Docusign or similar software. The document will then be ready to email to DOO@verifpoint.com or to  DOO Recredentialing for revalidation. 

Completed samples of Disclosure of Ownership and Conflict of Interest forms:

• Corporation Example
• Sole Practictioner Example

View step by step instructions for the completion of the form