OW+Denture+Pred+Form_4213 by nuhman10


									                                                             Ontario Works Denture Pre-determination Form
                                                                                                  Community and Health Services Department
                                                                                                             Ontario Works Dental Program

                                                                                                                               OW               ODSP
Ontario Works Member ID:                                                      OR Dental Authorization #:
   (from Statement of Assistance or Direct Deposit Statement)                                   (see reverse if drug card not available)
Patient Information
Drug Benefit Eligibility Card #                                               Date of Birth (dd/mm/yy)
Last Name                                                                     First Name
Mailing Address
                       Street                                                 City/Town                                        Postal Code

Parent/Guardian Name                                                                              Telephone
To determine eligibility for dentures for the Ontario Works/ODSP client, the following information is required:
              Completed Ontario Works Denture Pre-determination Form
              Most Recent Radiographs
              Treatment Plan
Please answer all questions listed below. Incomplete forms will be returned.

1. Is this an initial appliance?                  Upper:     Yes         No                 Lower:        Yes          No

  If you answered yes, provide the
  dates of the relevant extractions:
  If you answered no, provide reasons
  for replacement and year of
  construction of denture(s):
2. Indicate if any of the missing teeth in the upper or
   lower arch have been previously replaced with a
   prosthetic appliance.
3. Check the box next to the
   tooth numbers of missing           18      17   16        15    14       13     12      11           21      22      23     24      25     26     27       28
   teeth or teeth to be               48      47   46        45    44       43     42      41           31      32      33     34      35     36     37       38
   extracted, in both arches:

4. For Partial Dentures, indicate when the patient last
                                                                   1 year         2 years          3 years           4 years        5 years        5+ years
   had a complete examination by a dentist:

5. Indicate abutment teeth for the denture(s):
6. Has all restorative, periodontal and
                                                           Yes            No
   endodontic work been completed?
7. Are all remaining teeth restoratively,
                                                           Yes            No
   periodontally and endodontically sound?
  If no, explain

8. Patient’s oral hygiene is:         Excellent             Good                 Fair                 Poor

I understand that approval is required before starting treatment to be reimbursed by the York Region Ontario Works Dental Program.

         Signature of Denture Provider                                                             Print Name
Please return this completed form,     The Regional Municipality of York
radiographs and treatment plan to:     Ontario Works Dental Liaison, Community and Health Services Department
                                       17250 Yonge Street, 3rd Floor, Newmarket L3Y 6Z1

This personal information is collected under the authority of s.41(1) and (2) of the Ontario Works Act, 1997, S.O. 1997, c. 25, Sched. A. The
information will be used to provide administration of publicly funded dental assistance programs. Documents are maintained pursuant to the
Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. M.56 and the Personal Health Information Protection Act, 2004,
S.O. 2004, c. 3, Sched. A. If you have any questions regarding the collection and use of personal information, please call 1-888-256-1112.
                                                     Note: Fillable form available at www.york.ca/teeth

                                                                        1 of 2                                                                4213 08 2010
                                                         Ontario Works Denture Pre-determination Form
                                                                               Community and Health Services Department
                                                                                          Ontario Works Dental Program

Dental Authorization Contacts

If a patient does not have a Drug Benefit Eligibility Card at the time of treatment, you must call the OW office serving the
patient to request a Dental Authorization number.

Newmarket Office
Community and Health Services                                       905-895-5166    ext. 2227
62 Bayview Parkway                                                                  ext. 2229
Newmarket ON L3Y 3W3

Georgina Office
Community and Health Services                                       905-989-1883    ext. 2914
24262 Woodbine Avenue                                                               ext. 2902
Keswick ON L4P 3E9

Richmond Hill Office
Community and Health Services                                       905-762-2095    ext. 2615
50 High Tech Road, 3rd Floor                                                        ext. 2637
Richmond Hill ON L4B 4N7                                                            ext. 2638
                                                                                    ext. 2628
Vaughan Office
Community and Health Services                                       905-850-3490    ext. 2537
3901 Highway #7, Suite 501                                                          ext. 2512
Woodbridge ON L4L 6B2


For questions about dental billing, claims and pre-determinations, call the Ontario Works (OW) Dental Liaison at
905-830-4444 ext. 2075.

For a copy of the York Region OW Schedule of Denture Services & Fees, fax your request to 905-895-1697.

Visit www.york.ca/teeth for more information about the York Region OW Dental Program.

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