Name
*
First Name
Last Name
Email Address
*
Home Phone
*
Country
(###)
###
####
Cell Phone
Country
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
County
Date of Birth
*
MM
DD
YYYY
Race
*
Ethnicity
*
Marital Status
*
Number of people in the household:
Are you a veteran?
Are you a spouse or child of a veteran?
List contact person NOT living with you
*
Contact Phone
*
Country
(###)
###
####
Relationship to you
*
Contact Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you hear about our Dental Assistance Program?
*
Have you been in the program before?
*
If Yes, When?
Major disabilities or health problems for each person applying:
Are you covered by Medicare Part A or Part B?
Do you require wheelchair access?
Employer
Do you have dental insurance?
*
If Yes, please list name of insurer and policy number:
Do you receive Medicaid benefits?
If you recently applied for Medicaid and were denied, send a copy of the denial letter.
If Yes, does it include dental coverage?
Explain:
If Yes, do you have a spenddown?
Name of the last dentist you saw:
Dentist Phone
Country
(###)
###
####
Date of last dental visit
(estimate if necessary)
MM
DD
YYYY
Reason for visit:
Current Dental Needs
Briefly describe dental needs of each applicant.
Do you have a car for transportation?
How far can you travel for dental treatment?
How will you get to your appointments?
Additional Information
Please use this space to explain any additional information you feel our Dental Program should have
Please read the following statements. If you understand and agree to the conditions, please check each box and date the form at the bottom
*
To the best of my knowledge, the information provided on this form is a full and accurate disclosure of my current physical, mental and financial status.
*
Full Name
*
First Name
Last Name
Date of Signature
*
MM
DD
YYYY
