MDIS DVH Provider Application

Please complete and submit the form below or click here if you prefer to complete a fillable PDF form that can be printed and mailed or emailed.

MDIS DVH Policy Provider Agreement

Referral List Criteria

Missouri Dental Insurance Services, Inc. (“MDIS”), a Missouri Insurance Licensed Producer Entity, will be offering a dental, vision and hearing (“DVH”) insurance policy plan to any Missouri consumers found to be appropriate insureds under a policy of insurance underwritten by Manhattan Life Insurance Company (“MLIC”).

A Dental Panel Referral List will be compiled by the MDIS representing a list of Missouri Dental Association ("MDA") members who desire to be included on the panel of listed dentists for the dental portion of the DVH policy offered to the insured patients. In order to be included on the list of the ​dentists to be provided to the potential insured patients, a dentist is to comply with the following criteria to become eligible and to remain on the panel list:

  1. Be at all times a member in good standing with the MDA.
  2. Membership shall be validated by MDIS with information provided by MDA on a regular basis.
  3. Be at all times approved by the insurer, MLIC, as a MLIC Dental Provider under the MLIC DVH Policy of Insurance, in order to be eligible for referral to insureds.
  4. All dentists on the Dental Panel Referral List voluntarily can be removed from the list with thirty (30) days prior written notice to MDA and MDIS.
  5. Any dentist on the list will be removed from the list at any time the dentist is no longer an MDA member in good standing, effective the date the member is no longer in good standing and without prior notice of removal from the list.
  6. All provider claim adjudication communications and inquiries will be handled directly between the dentist and the insurer, MLIC.​

Application for Inclusion

Practice Information

Dentist Information

Signature Confirmation

Managing Practice Partner may sign by and on behalf of all dentists applying if entire practice applies to become eligible.
Please check the box to accept the terms of this application.
Your typed name and checking the box to accept the terms serves as your signature on this application to be listed on the MDIS Dental Referral List.