Provider Relief Credit

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As a response to the COVID-19 pandemic, all licensed dentists in Michigan, Ohio and Indiana who are currently practicing, and have an active license and Type 1 NPI number, are eligible to receive a $1,000 grant from Delta Dental of of Michigan, Ohio, and Indiana. To ensure that the grants are used towards valid practice expenses, the grants will be provided in the form of a credit on account with Henry Schein. The grant is to the recipient and can be used toward existing account balances or toward any future purchase of dental products and/or services from Henry Schein.

HOW TO REDEEM CREDIT:
 

YOU DO NOT NEED TO SUBMIT THIS FORM IF YOU HAVE:
An active license,
A Type 1 NPI number, AND
A current Henry Schein account

Henry Schein will automatically credit your account. 
 

If you are part of a group practice, you have two options:

  1. Request that your credit go to your group practice’s current account by filling out the form and including your practice’s Henry Schein account number. You must check the box at the bottom of the form to designate that your credit go to your group practice account.
     
  2. Open your own/new Henry Schein account where the credit can be applied. Call 844-269-4204 or set up your account on the Henry Schein website. Then, include your new account number in the form and fill out the top portion "Dentist Section" only.

Provider Relief Credit FAQs

View FAQs


NOTES:
Asterisk (*) denotes a required field.

HENRY SCHEIN ACCOUNT NUMBER:

(NOTE: If you would like your credit applied to an group practice/office account, check the box at the bottom of the form.)


DENTIST SECTION:

 

 

 

 

 

 

 

 

 


DESIGNATED OFFICE SECTION (in lieu of personal acceptance of grant): 

Only complete this section if you are assigning your credit to a group/practice Henry Schein account.


 

 

 

 

 

 

 

 

 

Today

 

ASSIGN TO GROUP/PRACTICE ACCOUNT: I do not personally incur my practice expenses. I would like my $1,000 grant from DeltaDental of Michigan, Ohio, and Indiana to which I understand that I am entitled to insteadbe paid as a grant to the eligible practice account listed above as the DesignatedOffice to defer the costs of care for my patients. I understand that, by making thisrequest, I will no longer be eligible to personally receive the $1,000 grant and once Icheck this box and submit this form, the $1,000 grant, if made, will be paid only to theDesignated Office account indicated above (to the extent it is deemed eligible). I waiveany and all personal rights or entitlement to this grant.

 

REQUIRED ACKNOWLEDGMENT: By checking this box, I acknowledge that I am the person whose name appears within this document and I agree with the terms and conditions herein.