Open Dental Software Manual - DoseSpot Registration

Provider Clinic

First Name

Last Name

Phone #

Practice Administrator Email

DEA #

Personal NPI #

Birthdate

Office Name

Register for EPCS?

I acknowledge and accept the DoseSpot service fees as listed at https://www.opendental.com/site/fees.html and agree to pay these charges. I acknowledge that the fees will start when Open Dental sends me the provider ID and that they are not refundable. If I choose to cancel DoseSpot service, I will notify Open Dental no less than 10 business days prior to the start of my next billing cycle.

Name of person submitting form

Clinic/Practice Name

Address

City

State

Zip Code

Phone #

Fax #

Practice Administrator* (First and Last)

Practice Administrator Email

ADSO Member or 75+ Providers?

list all non-providers (proxy clinicians) who will access DoseSpot and their email addresses (required if using stand-alone)

*Designate a staff member (typically an office manager) who will be the point of contact and own the DoseSpot sign up process for providers and proxy clinicians. This person will need admin permissions in Open Dental and must be a non-provider. To register additional proxy (non-provider) users please send an email with their first and last names to erx@opendental.com.

We are not currently using Open Dental. I acknowledge that by signing up for the stand-alone version of DoseSpot the information will not be integrated with my Open Dental. Once we sign up with Open Dental, this information will not transfer into my Open Dental database.

*When you submit this form, an email for your records will be sent to the Practice Administrator's address entered above with instructions on your next step. After receiving the email, your next step is to forward that email to eRx@opendental.com when you are ready for Open Dental to generate the ClinicID and/or Provider ID. Please note that once the IDs are generated charges will be initiated and because they involve multiple third parties, they cannot be refunded by Open Dental regardless of whether or not the provider completes the registration process. Please notify Open Dental immediately if you do not wish to proceed at any point in the process, in order to minimize the charges.

DoseSpot Registration Form

Requirements