United Concordia welcomes the opportunity to partner with
you and your dental office and invites you to become a
member of our growing network of dental providers.
The forms below are provided for your convenience in
becoming a participating dentist with United Concordia.
To apply for participation with United Concordia, you
will need to do the following :
Print a TDP Addendum (this is for your records)
Fill out a Participation Agreement
Fill out a Participation Application
Completed Participation Agreement and Application should be
mailed or faxed to :
United Concordia Companies, Inc.
Provider Data Management
P.O. Box 69415
Harrisburg, PA 17106
Please note, these forms are in a pdf printable format.
You will need Adobe Acrobat Reader version 4.0 or
higher for your computer to print these enrollment
forms. To get Acrobat, just click on the "Get
Acrobat" button.
The Participation Agreements and Applications are State
specific. Please choose from the state dropdown list
below to obtain the correct application and agreement
for your dental practice.
