DENTAL TREATMENT PERMISSION FORM by tracy12

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									DENTAL HEALTH PROGRAM FOR CHILDREN IN NEED

Miles of Smiles
MISSION: The dental health program is designed to provide dental health services to children whose family situation does not allow funding for this basic health need. The program does not provide comprehensive dental care or orthodontic care. Addressing the proper care of their teeth will enhance the children's sense of self worth and confidence. SCOPE OF SERVICES: Students in need will be identified by the School Health Nurses of the Warren County School System, staff of Warren County Department of Social Services or Skyline Cap Head Start. Examples of eligible participants may include but are not limited to students on the free or reduced lunch program; family is welfare recipient, number of children in the family, prolonged illness in the family, whether or not the parents are employed, etc. Approximately $150.00 will be spent on each child. Of course, sometimes, in special circumstances, exceptions will be made. AUTHORIZATION FOR SERVICES: All requests for dental services will be documented on all applicants on the Eligibility Information Form and the Dental Treatment Permission form. (See attached) Appointments for dental care will be made by the school health nurses or requesting agency. They will contact the parents of the child for filling out the appropriate forms and regarding transportation to and from the dentist. Arrangements for transportation will be made as necessary with school personnel. Children MUST be accompanied by the parent or guardian to the appointment. The form, "Dental Treatment Permission Form" should be copied. Original is taken to the dentist; one copy is kept on file at the school and at the WCCHC. FINANCIAL STRATEGY: Participating dentists are to be instructed to send their bill to Warren County Community Health Coalition, P.O. Box 2058, Front Royal, VA 22630, ATTENTION: Dental Health Program. Reimbursement will be from a special account set up just for this purpose. The procedure will be conducted as follows:  The School Nurse/Agency Staff should fax all applicable forms to the Warren County Community Health Coalition (WCCHC), notifying them of the amount of funding needed (if known), Dentist accepting care, potential Date of Service.  Care should not be provided to the participant until the referral source has been notified that the request has been approved.  All requests will be approved or denied within two business days.  The WCCHC representative logs all participants and arranges for payment as the bills arrive. EMERGENCY CARE: In rare cases, the WCCHC will automatically pre-approve up to $100 worth of care without receiving the applicable forms. Any continued care would need to be approved as per the procedures listed above.

REV: 12/20/2002 jjr

PROCEDURE: 1. Dental Health forms for requesting services are to be sent to School Nurse or Agency Contacts for appointments to be made. The School Nurse/Agency is to have the eligibility form completed and faxed in to the WCCHC office. If a student is on free or reduced lunch, the family is on welfare, or if the family is eligible for FAMIS they are automatically eligible for care. (Eligibility form must be filled out on each case). Otherwise, the completed application and financial information will be reviewed and the amount of assistance will be assigned within two business days. All requests for dental aid should be submitted on the Dental Treatment Permission form and include the parent's telephone number if there is one. Call the Warren County Social Services department at 635-3430 to verify welfare status if Medicaid card unavailable. Nurse/Staff should send a copy of the form, "Dental Treatment Permission" home with the student for his/her parents to fill out and sign. Upon receipt, a copy of the form is to be kept on file at the school and at the WCCHC and the original sent with the student for the first appointment. The permission form is only required for the first appointment. The school Nurse/Agency Staff is to call the participating dentist and set up an appointment for the student. Make the appointment for at least a week from the date you call for it so that the student will have time to take the permission slip home for his/her parents to sign and bring it back to school. The school nurse is to call the appointment to the WCCHC (636-6385) representative in order to maintain a log of appointments made for comparison against the dental bills when they arrive. Bills for dental services will be submitted to Warren County Community Health Coalition, Dental Health Program.

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Important Phone Numbers:

Dr. Harry Heard/Dr. Todd Mullins Dr. Harry Sartelle Dr. Phillip Wines Comprehensive Dental Care (Dr. Dickerson, Dr. Boussey) Contact: Donna E. Wilson Morrison Elementary A.S. Rhodes Elementary Leslie Fox Keyser Elementary Ressie Jeffries Elementary Hilda Barbour Elementary Warren County Middle School Warren County Jr. High School Warren County High School Skyline Cap Head Start Warren Co. Social Services

635-4567 635-2493 636-6129 635-9800

635-4188 635-4556 635-3125 636-6824 622-8090 635-2194 636-3199 635-4144 635-2362 635-3430

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CONFIDENTIAL
Miles of Smiles

Eligibility Information Form
SECTION I: Name of Child: Father's Name: Mother's Name:

STREET ADDRESS:__________________________________ CITY/STATE:___________________ ZIP: HOME PHONE: WORK PHONE: (F) (M)

NUMBER OF MEMBERS IN THE HOUSEHOLD: ________________ AGES:

Have you applied for Medicaid? ___Yes ___No (check One) Have you applied for FAMIS? ___Yes ___No (check One) Does child receive free or reduced lunch? ___Free ___Reduced SECTION II:

(If Yes) ___Accepted ___Denied (If Yes) ___Accepted ___Denied

(check One) (check One)

(check One) IF YOU HAVE BEEN APPROVED FOR MEDICAID, FAMIS, OR FREE OR REDUCED LUNCH, SKIP SECTIO IIi OF THIS FORM

TOTAL NET DISPOSABLE MONTHLY INCOME FROM ALL SOURCES (Income verification may be required) ______ Wages or Self-Employment Income ______ Retirement Benefits (Veteran, Railroad, Civil Service) ______ Rate x ______ Hours ______ Spouses/Parents Wages ______ Other Income/Rental, etc. (Specify) ______ Rate x ______ Hours ______ Social Security/SSDI ______ Child Support/Alimony ______ Supplemental Security Income ______ Unemployment Benefits, Workman’s Comp, ADC, Food Stamps, General Relief, Rental Assistance _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________

TOTAL NET DISPOSABLE FAMILY INCOME: (after taxes): FIXED MONTHLY EXPENSES: Actual Rent or Mortgage Payment & Real Estate Taxes Actual Utilities (If UNKNOWN, 1-3 people $180.00, 4 or more $360.00) Actual Transportation Expenses Actual Telephone (If Unknown, $50) Actual Food (If Unknown, $110.00 per person) Actual Child Care Actual Medical Bills & Medical Insurance Actual Clothing (If Unknown, $50 per person) TOTAL OF ALL FIXED MONTHLY EXPENSES
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(If Unknown, $300)

Please list other expenses not previously recorded (note that the above listed categories are the only approved fixed monthly expenses. Other expenses listed here may be considered at the discretion of the Executive Director): ________________________________________________________________________________________________ TOTAL MONTHLY INCOME TOTAL MONTHLY EXPENSES DISPOSABLE INCOME (total monthly income less expenses) _________________________ _________________________ _________________________

SECTION III:
I certify that to the best of my knowledge, this is a true and complete financial statement and that I will contact the WCCHC to inform them of any substantial change in income or expenses. I understand that this form or copies of this form will be placed in the file (s) of each participants listed herein.

_________________________________________ Parent's Signature

_______________ Date

Official Use:
VERIFICATION OF INCOME: (requested? YES / NO ) (received? YES / NO ) ______ A copy of check stub(s) ______ Last year’s tax return ______ A copy of insurance card ______ Signed and dated Insurance Form ______ Copy of Driver’s License, SS Card ______ Verification of or denial of Unemployment Compensation ______ Other ______ Update

___Accepted ___Denied

_____________________________________________ Signature

__________ Date

DATE

SERVICE PROVIDER

DESCRIPTION OF SERVICE

AMOUNT $ $ $ $ $ $ $ $ $ $

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DENTAL TREATMENT PERMISSION FORM Warren County Community Health Coalition Name of Child:____________________________________________________________
Last First Middle

Mailing Address:_______________________________________________________________________ ______________________________________________________________________ City State Zip Date of birth: _________________________ Home phone: _______________________________

Fathers Name: ______________________________ Occupation: _______________________________ Mothers Name: ______________________________ Occupation: _______________________________ Please complete the following information for the dentist’s record.

Answer YES or NO

1).

Has child had a reaction to:

Anesthetics _____________________ Penicillin _____________________ Sulfur Drug _____________________ _____________________ _____________________ _____________________ _____________________ _____________________

2).

Has child had:

Heart Trouble Rheumatic Fever Diabetes Hemophilia Epilepsy

Name of Family Doctor: __________________________________________________________

I hereby give permission for my child ________________________________________________ (Name of Child) to receive dental treatment from any participating dentist through the Warren County Community Health Coalition Dental Health Program. I understand that this program is paid for, in part through public support. I will do my part by keeping scheduled appointments or by calling ahead if I must reschedule.

____________________________________ Signature of Parent or Guardian

______________ Date

REV: 12/20/2002 jjr


								
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