How To Get Started Confirm your office has internet access: To utilize EDS your office must have DSL or Cable internet access. Dial-Up Internet is not supported any longer by EDS.

Complete the EDS Enrollment Forms and fax them to the number at the bottom of the forms: Please be sure to fill out all areas of the forms. Any missing information will delay processing.

Schedule your free installation and training: Once we receive the completed paperwork, one of our friendly staff members will contact the office for installation and training. The installation will not interfere with your daily work flow. It will be business as usual for your staff and patients.

Your office will receive a call from us at the time you specified so that we can perform the installation and training session: Our installation/training department will contact your office on the day and time that was scheduled with your staff member. We will perform the installation and training, as well as test the system by submitting a few test transactions. This process will take between 30-60 minutes. The length of time is dependent on the needs of the person(s) in your office that are being trained and the number of computers that need to be installed.

Start saving with EDS: With the use of the EDS Bridge and Interactive Web Portal with your practice management program to submit and manage your electronic transactions.

It’s that Easy! Call Electronic Dental Services at:(800)482-3518 x800 to get started!

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Electronic Claims License Agreement

PHONE: (800)482-3518 ELECTRONIC CLAIMS LICENSE AGREEMENT PLEASE FAX THIS FORM TO: (651)389-9152 Form: EDS25MNDA6FREE

Please complete information in all Sections. Missing information within any one section will delay processing. Thank You.

1. Practice Information: * required fields

*Practice Name:___________________________________________________________________________________________________

DBA:____________________________________________________________________________________________________________

*Contact Name/Title:_____________________________________ *Contact Email:_______________________________________________

*Practice/Group Type 2 NPI #: (not individual Dr. NPI) ____________________________ *Tax ID #:_________________________________

*Treating Address:_____________________________________*City:______________________ *State:____ *Zip:_________+ *_______

*Practice Phone #: ____________________________ *Fax #:_____________________________

*Practice Email:_____________________________________________________________________________

If the Treating address and Claim Pay to Address are different, please complete below:

Claim Pay to Address:_____________________________________City:______________________ State:____ Zip:_________+ _______

2. Provider(s) Information: (if you have more providers, please attach their information on another sheet and attach/send with agreement)

*Provider's Name:_______________________________________ *Provider NPI:___________________ *License Number:___________

*Provider's Name:_______________________________________ *Provider NPI:___________________ *License Number:___________

*Provider's Name:_______________________________________ *Provider NPI:___________________ *License Number:___________

*Provider's Name:_______________________________________ *Provider NPI:___________________ *License Number:___________

3. PMS System Information: *Software Package Name:____________________________________________ Version Number:______________

4. Payer Information: Approximate number of claims submitted to all carriers each month: ________________________

5. Electronic Claim Submission Service: Rate

Electronic Claim Submission Service and Real Time Claim Status: EDS agrees to give Customer claims processing at

$0.25 per claim.

EDS agrees to give MDA Members 6 FREE months of claim service and Real Time Claim Status. The 1st 60 days and the 9th and 12th

month of the first year and the 6th and 12th month of the second year will be considered FREE months. Non-MDA Members will receive

2 FREE months of claim service and Real Time Claim Status.

$0.25 per claim

This service must be

checked - MDA MEMBER

6. Additional Services: Currently available on select software packages, please inquire with EDS for availability for your software. Rate Choose optional

services below a. AutoPost: $.15 per claim payment posted

**Must select All ERAs to use AutoPost

$.15

Per claim

b. All ERAs: $14.95 per office/per location **Must be selected if choosing AutoPost.

(if combined with Eligibility, cost is $19.95 per location for both)

$14.95 per location

c. Eligibility: $14.95 per office/per location.

(if combined with All ERAs, cost is $19.95 per location for both)

$14.95 per location

d. Statements: $.68 per Statement: Requires Bank Draft payment

Includes: Full Color Front and Back, Custom 8.5x11 Virtual Document(s) with Perforation, #10 Window

Envelope, #9 Window reply window envelope, Processing, Printing, Inserting and mailing, USPS postage at first

class bulk presort rate, Copy of Statement.

Upfront Fees:

Estimated number of Statements per month______x $.43= $__________ or Minimum of $50.00

whichever is greater.

Additional Fees:

Multiple Page(s) $.15 per page

USPS NCOAlink Processing $.44

(address forwarding)

Optional Services:

Duplex Printing $.02 per page

Actual Statement .pdf copies - $.04 per page

E-Delivery via E-mail with valid E-Mail address provided $.27 per statement.

$.68

Per statement and

additional fees if

applicable

Check Optional

e. Medical Claims – Manual Medical claim entry

$.50 Per Claim

f. Accounts Receivable Ageing - 1st 30 days FREE. Please choose below: $49.95 1 provider, 1 location $59.95 2 providers, 1 location $69.95 3 or more providers, 1 location

Enter # of Providers

Electronic Claims License Agreement

PHONE: (800)482-3518 ELECTRONIC CLAIMS LICENSE AGREEMENT PLEASE FAX THIS FORM TO: (651)389-9152 Form: EDS25MNDA6FREE

7. *Two Payment Options: (select one)

Credit Card Information Credit Card Type: □ Visa □ Master Card □ American Express

Credit Card Number: ______________________________________ Expiration Date: ____________ 3 or 4 digit security code :__________(From the back of the card)

Individual Name on Card: _______________________________________________

*Credit Card Billing Address:_____________________________________________________________

City:______________________________________State:____________Zip:______________-__________ Signature of Card Holder: _____________________________________________________________________________________

ACH or Debit Card (circle one) I (we) hereby authorize Electronic Dental Services (EDS) (THE COMPANY) to initiate entries to my (our) checking/savings accounts at the financial institution listed below (THE FINANCIAL INSTITUTION), and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until THE COMPANY is notified by me (us) in writing to cancel it in such time as to afford THE COMPANY and THE FINANCIAL INSTITUTION a reasonable opportunity to act on it. Name of Financial Institution:____________________________________________________________________________________________ Financial Institution Routing Number:______________________________________________________________________________________ Account Number:__________________________________________________________________ Checking or Savings (circle one) I authorize EDS to collect payment for services I have selected to use, and by my signature below acknowledges and agrees to the terms and conditions of

the attached software license agreement and this order form.

CUSTOMER (principal doctor’s signature): ______________________________________________________ DATE: ________________

Please tell us how you heard about Electronic Dental Services?_____________________________________________________________

8. Check List for Additional Electronic Claims Processing Enrollment The Insurance Carriers listed below require additional registration either via forms or the carrier’s online tools. Please select those that apply to your practice and review required electronic claims enrollment at www.edsedi.com . Please include all Provider/Location numbers issued by carrier. If you do not have your Provider/Location numbers, please contact the carrier in question for your numbers. Blue Cross of Idaho (CBID1) **Forms Blue Cross of IA (CBIA2) **In State Only Blue Cross of IA (FEP claims only) (CBIA1) **In State Only Blue Cross of KS (CBKS1) **In State Only Blue Cross of Kansas City Missouri (47171) **Form Blue Cross of LA (23739) **In State Only Blue Cross of MA (CBMA1) Blue Cross of MS (CBMS1) **Forms Blue Cross of NJ (Horizon) (22099) **Form Blue Cross of ND (ND Dental Services (CX004) **Online and Forms Blue Cross of RI (CB870) **Forms Blue Cross of TN (CBTN1) **Forms Blue Shield of NY - Eastern (CBNYE) **Form Blue Shield of NY – Western (CBNYW) **Form CareSource (CKOH2) **Forms Cook Children’s Health Plan (CPPCH) **Online Deseret Mutual Benefit Administrators (CX089) **Forms Indiana Children’s Special Healthcare(CX070) **Forms Horizon (Blue Cross of NJ) (22099) **Form Medicaid of AL (CKAL1) **Forms Medicaid of AK (CKAK1) **Forms Medicaid of CA (Denti-Cal) (94146) **Call Payer Medicaid of Delaware (CKDE1) **Forms Medicaid of District of Columbia (DC) (MCDC1) **Forms Medicaid of FL (CKFL1) **Forms Medicaid of IN (CKIN1) **Forms

Medicaid of IA (CKIA1) **Forms Medicaid of KY (CKKY1) **Forms Medicaid of ME (CKME1) **Forms Medicaid of MI (CKMI1) **Online Medicaid of MN (CKMN1) **Forms Medicaid of MS (CKMS1) **Forms Medicaid of NH (CKNH1) **Forms Medicaid of NC (CKNC1) **Forms Medicaid of NE (CKNE1) **Forms Medicaid of ND (CKND1) **Online and Forms Medicaid of NJ (CKNJ1) **Forms Medicaid of NM (CKNM1) **Form Medicaid of NY (CKNY1, CKNY2) **Forms Medicaid of NV (CKNV1) **Forms Medicaid of OR (CKOR1) **Forms Medicaid of PA (CKPA1) **Form Medicaid of RI (CKRI1) **Form Medicaid of TX (CKTX1) **Form Medicaid of UT (CKUT1) **Online or Forms Medicaid of VT (CKVT1) **Forms Medicaid of WA (CKWA1) **Online Medicaid of WV (CKWV1) **Form Medicaid of WY (CKWY1) **Forms PEHP (Public Employees Health Program (CX080) **Online Triple-S Puerto Rico (97300) **Forms

Please review ERA enrollment requirements at: www.edsedi.com.

Electronic Claims License Agreement

PHONE: (800)482-3518 ELECTRONIC CLAIMS LICENSE AGREEMENT PLEASE FAX THIS FORM TO: (651)389-9152 Form: EDS25MNDA6FREE

1. Services Provided. Subject to the terms of this Software License Agreement (“Agreement”), EDS will electronically send, directly or through affiliated clearinghouses,

claims submitted by the Practice set forth above (hereinafter “Customer”) through software and/or interactive websites provided by EDS (“Software”) to designated

insurance carriers (“Carriers”), subject to limitations set by Customer’s Carriers. All other claims will be printed to paper and mailed to the appropriate Carriers via first

class mail or faster. It is understood that third party recipients (e.g., insurance companies, claims clearinghouses, etc.) are not a party to this Agreement. Claim

submission services and other services included under this Agreement (“Services”) are provided pursuant to the rates set forth above. Customer agrees that EDS shall be Customer’s exclusive provider of Services during the term of this Agreement.

2. License Grant. EDS grants Customer, and Customer accepts, a non-exclusive, non-transferable license (without the right to sublicense) to use the Software for the sole

purpose of receiving the Services provided under this Agreement. This Agreement only provides a single use license to use the Software. Customer agrees to keep

confidential and use its best efforts to prevent and protect the contents of the Software from unauthorized disclosure or use. EDS may provide updates to Software from time to time, subject to a nominal charge to cover duplication and shipping costs. EDS reserves the right to terminate this Agreement if Customer does not maintain the

most current version of the Software.

3. Limitation of Use. Customer may not: 1) copy, except to make one copy of the Software solely for back-up or archival purposes; 2) transfer, distribute, rent, lease or sublicense all or any portion of the Software to any third party; 3) translate, modify, adapt, decompile, disassemble, or reverse engineer the Software in whole or in part;

or 4) modify or prepare derivative works of the Software. EDS reserves all rights that are not expressly granted to Customer.

4. Ownership Rights. All intellectual property rights including trademarks, service marks, patents, copyrights, trade secrets, and other proprietary rights in or related to the

Software are and will remain the property of EDS or its licensors, whether or not specifically recognized or protected under local law. Customer will not remove any product identification, copyright notices, or other legends set forth on the Software.

5. Termination. Customer may terminate this Agreement and discontinue use of Software at any time by providing thirty (30) days prior written notice to EDS, and upon

termination shall remove and destroy the Software from Customer’s computer systems. Customer shall remain liable for any outstanding balance on Customer’s account

and Customer understands that no monthly fees will be prorated for partial months of service. EDS reserves the right to terminate Customer’s use of Software or Services at any time, without refund or notice, in the event that the EDS believes, in its sole discretion, that Customer is not in compliance with the terms and conditions of the

Agreement.

6. Warranty Disclaimer and Limitation of Liability. EDS does not warrant that the functions contained in the Software will meet Customer’s requirements or that

operation of the program will be uninterrupted or error-free. The entire risk as to the results and performance of the Software is assumed by Customer. THE SOFTWARE IS FURNISHED, “AS IS” WITHOUT ANY WARRANTY OF ANY KIND, AND EDS HEREBY DISCLAIMS ALL WARRANTIES, EXPRESS,

IMPLIED OR STATUTORY IN RESPECT OF THE SOFTWARE INCLUDING, WITHOUT LIMITATION, ALL IMPLIED WARRANTIES OF

MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE, AND ANY WARRANTIES AS TO NON-INFRINGEMENT.

EDS’ ENTIRE LIABILITY UNDER, FOR BREACH OF, OR ARISING OUT OF THIS AGREEMENT, IS LIMITED TO A REFUND OF THE PURCHASE PRICE

OF THE SOFTWARE OR SERVICE THAT GAVE RISE TO THE CLAIM. IN NO EVENT SHALL EDS BE LIABLE FOR CUSTOMER’S COST OF PROCURING SUBSTITUTE GOODS. IN NO EVENT WILL EDS BE LIABLE FOR ANY INDIRECT, SPECIAL, CONSEQUENTIAL, INCIDENTAL, EXEMPLARY, OR

OTHER DAMAGES WHETHER OR NOT EDS HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSS OR DAMAGE. To the extent not otherwise

disclaimed in this Agreement, the maximum liability of EDS shall not exceed the average of any three consecutive months of service charges, even if EDS has been advised of the possibility of additional damages.

7. Customer Acknowledgement and Warranties. (a) Customer understands and agrees that EDS is not responsible for the Carriers processing of any dental or medical

claims. No promise or guarantee exists between EDS and Customer as to the time elapsed for processing of any claims by any Carriers, nor that Carriers will process any

claim in electronic or paper format. EDS makes no warranties or representations regarding the timeframes involved for processing and transferring of Customer claims.

(c) Customer understands and agrees that EDS is not responsible for the rejection of or the cost of processing claims due to incorrect or incomplete claim information

provided by the Customer. EDS or its personnel cannot change, add to or delete any claim data submitted to it by Customer (except that it may remove any zero fee procedure code). Any errors must be corrected by Customer and be resubmitted.

(d) Customer understands that EDS systems utilize databases containing information regarding patient eligibility and coverage. The accuracy therein of any such information is the responsibility of Carriers. EDS does not take responsibility for any inaccuracy of such information. Customer is responsible for the information

supplied to Carriers. EDS has no responsibility to Customer or its patients for any incorrect information supplied by Customer. The information provided by Customer

may be subject to periodic post payment audits by Carriers. Upon request by a Carrier, EDS shall make available a copy of this Agreement to such Carrier; however, credit card information will not be disclosed.

(e) Customer agrees that it will only use Software and Services for lawful purposes and any claims information or data submitted by Customer to EDS or insurance Carriers through EDS is legally within Customer’s control and Customer has any and all necessary permissions to submit such claims, data or information.

8. Indemnification. Customer agrees to indemnify, defend, and hold harmless EDS and its affiliates and their officers, directors, employees, agents, licensors and third

party suppliers from and against all losses, expenses, damages and costs, including reasonable attorneys' fees and court costs, resulting from any violation of these terms

and conditions or any activity by Customer or any other person accessing the Software or Service on Customer’s behalf.

9. HIPAA. Current federal guidelines, as stated by the US Department of Health and Human Services, and outlined within the Health Insurance Portability and

Accountability Act of 1996 (“HIPAA”) regulations, allow for the assignment and recognition of a “Business Associate” relationship, such as the one outlined in this

Agreement, between two organizations, whereas one of the organizations is authorized to perform certain functions and services for the other organization, as required by

federal and state regulations. EDS agrees to provide such services on behalf of Customer. EDS uses technical safeguards to ensure the privacy and integrity of all information transmitted to or from its system. Such safeguards include password protection, data encryption, connection monitoring and input/output verification. EDS

agrees to perform the Services as stated herein for Customer to enable Customer to comply with regulations promulgated under HIPAA, specifically pertaining to data collection and transfer between Customer and EDS as well as EDS and third-party entities, on behalf of Customer, using specifically mandated data content and format.

10. This Agreement states the entire understanding of the parties with respect to the subject matter hereof, and it cannot be altered or amended without a writing signed by

both parties. If any provision of this Agreement is held to be unenforceable, in whole or in part, such holding shall not affect the validity of the other provisions of this

Agreement. Customer may not assign this Agreement or any associated transactions without the written consent of EDS. The Agreement shall be governed by the laws of the State of Minnesota, without regard to the conflicts of laws or principles thereof.