For your application to be considered, you MUST:

  • Answer ALL questions.
  • SEND PROOF OF ENTIRE HOUSEHOLD INCOME (please send copies, proof of income will not be returned).  If you are employed, include your 3 most recent paystubs and a copy of last year's tax return.  If you are receiving other income, send public assistance or benefit award letters.  Send a copy of the denial letter if you were denied by Medicaid.
  • Check ALL boxes and enter ALL information in the "Digital Signature" section at the bottom of the form.
Name *
Name
Home Phone *
Home Phone
Cell Phone
Cell Phone
Address *
Address
Date of Birth *
Date of Birth
Race *
Ethnicity *
Marital Status *
Please answer in the format ______ years and _____ months.
Are you a veteran?
Are you a spouse or child of a veteran?
Contact Phone *
Contact Phone
Contact Address
Contact Address
Have you been in the program before? *
Are you covered by Medicare Part A or Part B?
Do you require wheelchair access?
$
Other Types of Income
Please enter all household income.
$
$
$
$
$
$
$
$
$
$
(List source)
$
$
Insurance information
Do you have dental insurance? *
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?
If Yes, do you have a spenddown?
$
Monthly health expenses:
$
$
$
$
Dental History
Dentist Phone
Dentist Phone
Date of last dental visit
Date of last dental visit
(estimate if necessary)
Briefly describe dental needs of each applicant.
Transportation
Do you have a car for transportation?
How will you get to your appointments?
Please use this space to explain any additional information you feel our Dental Program should have
Digital Signature
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 *
Full Name
Date of Signature *
Date of Signature