Tools and Resources

Tools

• Log in to Provider Portal
• Find a Dentist
• Recommend a Dentist

Broker Forms

• OraQuest - Application for Group Dental Plans
• Census / Enrollment Excel Template
• Itransact Access Request Form
• FCL - Application for Group Dental Service

Member Forms

• ADA Claims Form
• Wellcard RX Discount Program
• ACH / Bank Draft Authorization Form
• Individuals Credit Card Authorization Form

Employer Forms

• ADA Claim Form
• FCL Change Delete Form
• FCL Dental and VIsion Enrollment Application 2 Tier
• FCL Dental and VIsion Enrollment Application 3 Tier
• FCL Dental and VIsion Enrollment Application 4 Tier
• FCL Dental Enrollment Application 2 Tier
• FCL Dental Enrollment Application 3 Tier
• FCL Dental Enrollment Application 4 Tier
• FCL Dental Enrollment Application- Multi Plan Option
• ACH / Bank Draft Authorization Form
• Credit Card Authorization Form
• Itransact Access Request Form
• Wellcard RX Discount Program
• FCL - Application for Group Dental Service

Dental Provider Forms

• FCL Dental Credentialing Packet
• Louisiana Standardized Credentialing Packet
• CAQH Standardized Credentialing Packet
• Texas Standardized Credentialing Packet
• IRS W-9 Form
• ADA Claims Form
• Dina Dental Provider Change Form
• FCL Dental Provider Change Form