In addition to our Medicaid network, Advantage Dental also has a Commercial Dental Network that is utilized by PacificSource Health Plans. PacificSource offers a Medicare plan, which includes a supplemental dental benefit. While Medicare does not cover dental directly, Medicare plans often provide a supplemental dental benefit at the plan’s cost to create a more desirable overall benefit to members. As a result, the network providers need to complete a Disclosure of Ownership and Conflict of Interest Form to meet Centers for Medicaid and Medicare Services (CMS) requirements.
Medicaid Providers – Contracted with Advantage Dental Services, LLC
For Oregon Medicaid, the Oregon Health Authority requires that its Disclosure of Ownership and Conflict of Interest Form to be completed.
A fillable PDF version of the Oregon Health Authority’s Provider Disclosure Statement of Ownership and Control, Business Transactions and Criminal Convictions must be physically signed and faxed, emailed, or mailed to Provider Relations at the contact information below.
Commercial Network Providers – Contracted with Advantage Dental Plan, Inc.
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 emailed, faxed or mailed to Provider Relations at the contact information listed below.
Completed samples of Disclosure of Ownership and Conflict of Interest forms:
Sole Practitioner Example
Provider Relations Contact Information:
Mail To: 442 SW Umatilla Ave., Ste. 200
Redmond, OR 97756
View our Frequently Asked Questions for helpful information based on previous questions regarding the process and document.
View step by step instructions for the completion of the form