Verisys Secure Documents

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Health Plan Requesting Information:

DentaQuest (TAHP)

Credentials Request for:

KEY, ERIN J

You have provided all the information requested. Thank you!

Ways to Respond:

FAX OPTION: Click the Download button to receive your custom fax coversheet to attach as the first page of the Information Requested or Supporting Documents Requested faxed to Verisys.	Download
Fax #: 866-293-0421

- OR -

UPLOAD OPTION: Upload documents or provide a response for the Information Requested or Supporting Documents Requested on this page. Acceptable document formats to upload include: tif, jpg, pdf, gif, bmp, png, doc, docx.

Fax Option Instructions

How to provide the document or information requested by Verisys.

For documents (e.g., State License Copy or DEA Certificate):
Step 1:	Download and print the custom fax coversheet.
Step 2:	Fax the document, including the custom fax coversheet, to 866-293-0421.
For information not requiring a document (e.g., Licensing State, Complete Physical Address, or Date of Birth):
Step 1:	Click the Response button next to the item listed under the Information Requested or Supporting Documents Requested section.
Step 2:	Enter your name (as the Respondent) and then provide the information requested in the Message field.
Step 3:	Click the Submit button. The item will display as "Complete" once the response has been successfully uploaded.

How to get a blank copy of a document requested by Verisys.

Step 1:	Find the document listed in the Supporting Documents Requested section.
Step 2:	Click the Download button next to the document listed.
Step 3:	Print and complete the document.

What to do if you do not have the information requested, the document is not available, or the document does not exist.

Step 1:	Click the Response button next to the item listed under the Information Requested or Supporting Documents Requested section.
Step 2:	Enter your name (as the Respondent) and a message for that specific item, describing the reason why the information or the document cannot be provided.
Step 3:	Click the Submit button. The item will display as "Complete" once the response has been successfully uploaded.

Upload Option Instructions

How to provide the document or information requested by Verisys.

For documents (e.g., State License Copy or DEA Certificate):
Step 1:	Save the document on your computer or device. Acceptable document formats to upload include: tif, jpg, pdf, gif, bmp, png, doc, docx.
Step 2:	Click the Upload button next to the item listed under the Information Requested or Supporting Documents Requested section.
Step 3:	Browse to your document and click Open to upload it. The item will display as "Complete" once the document has been successfully uploaded.
For information not requiring a document (e.g., Licensing State, Complete Physical Address, or Date of Birth):
Step 1:	Click the Response button next to the item listed under the Information Requested or Supporting Documents Requested section.
Step 2:	Enter your name (as the Respondent) and then provide the information requested in the Message field.
Step 3:	Click the Submit button. The item will display as "Complete" once the response has been successfully uploaded.

How to get a blank copy of a document requested by Verisys.

Step 1:	Find the document listed in the Supporting Documents Requested section.
Step 2:	Click the Download button next to the document listed.
Step 3:	Print and complete the document.

What to do if you do not have the information requested, the document is not available, or the document does not exist.

Step 1:	Click the Response button next to the item listed under the Information Requested or Supporting Documents Requested section.
Step 2:	Enter your name (as the Respondent) and a message for that specific item, describing the reason why the information or the document cannot be provided.
Step 3:	Click the Submit button. The item will display as "Complete" once the response has been successfully uploaded.

Information Requested

Supporting Documents Requested

Respondent Name (First and Last Name):

Message:

Select a file to upload below:

The file you selected has an extension () that is not allowed. Allowed file extensions are:

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Error

Error: We're sorry, but something has gone wrong. We apologize for the inconvenience. Our staff has been notified. You may go back and try your request again or if you want to contact us directly, you may call us at 855-743-6161.

Supporting Documentation

Health Plan Requesting Information:

Credentials Request for:

Ways to Respond:

- OR -