232-Help/211 Donated Dental Service Application

232-HELP/211 Donated Dental Services

For Office Use Only:

Doctor:

Date:

Time:

Please print, complete and return this application to: DDS Program Director, P.O. Box 52763, Lafayette, LA 70505. Please fill in all of the blanks, answering questions as well as you can.

Clearly write in or type the following information. When finished, please read the Consent Statement at the end of this application. Sign and date the application if you understand and agree with the general terms and conditions of the program. When appropriate, a parent or guardian should sign.

Please make note of the following:

There is a waiting list for assistance through the DDS Program.

The DDS Program DOES NOT provide lifetime dental care; the dentist DO NOT donate routine cleanings or examinations after the initial treatment is complete. Cleanings, partials, dentures and full mouth extractions ARE NOT provided.

All dental work is restricted to the schedule set up by and mailed to you from 232-HELP/211 Donated Dental Program as directed by the Dentist providing the services.

___________________________________________ ____________________________________

Name Telephone #

___________________________________________ ____________________________________

Street Address Social Security #

___________________________________________ ____________________________________

Mailing Address (if different from above) Medicaid #

___________________________________________ ____________________________________

City State Zip Code Medicare #

_____/_____/____ _____ _________

Birth Date Age Gender

Ethnicity:

African Amer. Native Amer. Asian Hispanic White Other

*Please note: You are not required to check ethnicity- the information is for record keeping purposes only.

Physician(s)'s Name(s) ______________________________ Telephone #_______________

_______________________________ Telephone #_______________

Are you covered by any other insurance programs? Yes No

Dental coverage? Yes No

Please give the name of a family member, friend, case manager, etc. who can provide information regarding your case, serve as an emergency contact person, and if necessary, help with transportation or other problems which may arise.

Contact Person_____________________________________ Telephone ________________________

Relationship__________________________ If case manager, with what agency?________________

Please list any disabilities or health conditions you may have:

If you are a dialysis patient, on which days do you have dialysis? (For scheduling purposes):

Please list all medications you are presently taking:

Please list any allergies that you may have:__________________________________________________________

Do you require wheelchair access? Yes No

Do you walk with the assistance of a cane or walker? Yes No

Do you smoke or use tobacco products? Yes No

What is your dental problem? (Please be specific):

Do you feel you may need extractions? Yes No

How many? One Two Three Four Five

*Please note: The DDS Program DOES NOT provide assistance for full mouth extractions, dentures or partials.

Please name your last dentist____________________________________ Telephone # _________________

Date of last dental visit_________________________________________

If approved for dental assistance, how will you get to your dental appointment?

Self Friend/Family City Bus/Cab Other

Are you able to travel outside of your area if necessary? Yes No

Please list ALL the members in your household, and TOTAL income amount and source for each member of your household including yourself. *(Examples of Sources of income might include: Social Security, SSI. Additionally, how much do you/they receive monthly from each?)

Application can not be processed without this information.

How many people are in your household? _______

_______________________________________________ $____________/________________

(Name) (Relationship) (Monthly) (Source)

_______________________________________________ $____________/________________

(Name) (Relationship) (Monthly) (Source)

_______________________________________________ $____________/________________

(Name) (Relationship) (Monthly) (Source)

*Continue on back if additional space is needed.

Do you receive Food Stamps? Yes No If so, amount: $ _______________

Please list your major expenses:

Rent/Mortgage__________________________________ $____________________________

(amount per month)

Utilities________________________________________ $____________________________

(amount per month)

Phone_________________________________________ $____________________________

(amount per month)

Other__________________________________________ $____________________________

(amount per month)

PLEASE READ THE FOLLOWING CAREFULLY

232-HELP/211

Donated Dental Services Program

Consent Statement

I understand that I will need to provide personal information that includes, but is not limited to, my medical, dental and financial condition.

I give my consent for the referral coordinator to obtain information, relevant to my eligibility for the Donated Dental Services (DDS) Program, from my physician, dentist, individuals who know me and/or governmental or private agencies workers (this includes Social Workers, Case Workers, etc.).

I give permission for the referral coordinator to share pertinent information about my eligibility with any of above mentioned persons or more volunteer dentists in the DDS program.

I realize that application to the DDS program does not ensure that I will be referred for an examination or that I will be accepted as a patient following an examination.

I understand that the DDS Program will determine whether I am eligible for the program and, if so, will seek to refer me to a participating volunteer dentist. I further understand that the dentist, not the DDS Program, is solely responsible for diagnosis and any possible treatment that I might receive for my dental needs.

I understand that the dentist(s) have volunteered to treat my existing dental condition only and are not obligated to provide donated care in the future or maintain me as a patient. *PLEASE INITIAL: _____

I understand there is a waiting list for assistance through the DDS Program. The DDS Program DOES NOT provide lifetime dental care; the dentist DO NOT donate routine cleanings or examinations after the initial treatment is complete. Cleanings, partials, dentures and full mouth extractions are NOT provided. All dental work is restricted to the schedule set up by and mailed to you from 232-HELP/211 Donated Dental Program as directed by the Dentist providing the services. * PLEASE INITIAL: _____

I understand the importance of keeping all scheduled appointments. Failure to do so, without at least 24 hour notice to the dentist, can and will disqualify me from obtaining further treatment through the program.

To the best of my knowledge, the information provided by me is a full and accurate disclosure of my current physical, mental and financial status.

Print your name:

Signature

Date:

All programs are for the Acadiana area Only (2-1-1 Region IV)

Other qualifications may apply