Donated dental services (dds)


Dear Applicant:

In response to your request for more information regarding how to apply for donated dental
care, we are pleased to provide the following information and application for the Donated
Dental Services Program (DDS), a program of Dental Lifeline Network·Montana.
Dentists in Montana have volunteered to provide comprehensive dental care at no charge to
people of all ages who are permanently disabled, elderly or medically fragile and lack
adequate income to pay for needed dental care.
Qualifying individuals generally pay nothing, but occasionally, people in a position to pay
for part of their care may be encouraged to do so, especially when laboratory work is

If dental insurance and/or Medicaid cover any portion of your dental problems, you will be
asked to exhaust this resource.
Step One
Complete entire application. Page 5 of the application provides consent for the Program
Coordinator to obtain and share information about you and provides consent for your
physician to release medical information. Please return the application and both consent
forms by mail, fax, or online as directed. Keep this page for your records.
Step Two
When your application is received and you appear to be eligible for DDS, your application
will be placed on a waitlist in the order it was received. If you are not eligible, a letter of
denial will be sent to you. Depending upon the area you live in, the wait will be several
months or can be over a year. Please also be aware that we cannot return phone calls
about where you are on the waiting list due to the volume of calls we receive and trying
to help people through the program as quickly as possible.

Step Three
When your application comes to the top of the waitlist, DDS will contact you to tentatively
determine eligibility. If a volunteer dentist agrees to evaluate your oral health, you will be
given the information to schedule a consultation. Final acceptance into the program will be
made only after the consultation and when the specific treatment needs are established by a
volunteer dentist.

We are sorry you are experiencing a dental problem and we hope the Donated Dental
Services (DDS) program may be of some help.
Donated Dental Services (DDS) Program Coordinator

Donated Dental Services (DDS) P.O. Box 1154 Helena, MT 59624 APPLICANT INFORMATION
Contact Person Name (relative, friend, etc.): Have you received services through the DDS program before? MEDICAL INFORMATION
Do you have an artificial heart valve and/or stent? Yes Do you receive treatment for heart problems? Are you currently being treated for cancer? Do you have an artificial joint or other orthopedic hardware? Have you taken any of the following medications; Boniva, Prolia, Fosamax, Reclast, Actonel, Interferon? Yes Has your physician advised you that you need dental care immediately due to a medical condition? Major Disabilities or Health Problems (if your health problem is listed above please explain all in as much detail as possible, also include health problems not listed above): Page 1 of 5
How many natural teeth do you have remaining? # of Upper Teeth: # of Lower Teeth: How will you get to dental appointments? Please list other cities or how far you are willing to travel in order to get dental treatment: REFERRING AGENCY or AGENCY THROUGH WHICH YOU RECEIVE SERVICES
HOUSEHOLD FINANCIAL INFORMATION__________________________________________________________
Name of each person in the household: Age: If you are employed, place of employment: Is your spouse/significant other employed? If they are employed, Place of employment: Spouse's/significant other’s monthly employment income: $ Temporary assistance to needy families (TANF): If you are not receiving disability, have you ever applied? Page 2 of 5
Out of pocket health insurance: $ Life/Burial insurance: $ Are any family members able to contribute to costs of your dental treatment? Yes: Are any other sources available to help pay for dental care (i.e. churches, service organizations, other agencies, etc.)? Yes:

Use this space to elaborate on any information not sufficiently explained in other areas: Page 3 of 5
Please read the following statements
If you understand and agree to the conditions, please sign and date at the bottom of the form
1. Agreement – Release of Information
a. I understand that I will need to provide personal information that includes but, is not limited to medical, dental, and financial condition. I authorize the DDS Program to obtain information from, and share information with my physician(s), dentist(s), contact people I listed, and/or government or private agencies in order to determine my eligibility for the DDS program. b. I understand information provided by me or others as noted above may be given only to the volunteers involved in my treatment and will be held confidential. I authorize the DDS Program to share information with and obtain information about me with one or more dentist(s) volunteering in the DDS program. c. I understand if my disability is AIDS or HIV related, I authorize the DDS Program and Dental Lifeline Network • Montana to release information about my AIDS or HIV-related medical condition to one or more volunteer dentists in the DDS program and hold Dental Lifeline Network·• Montana harmless for doing so. I also understand that I have a right to revoke this consent at any time except to the extent that the person who is to make the disclosure has already acted in reliance on it. Furthermore, this consent will expire by 2. Eligibility & Treatment Understanding
a. I realize that my application to the DDS program does not assure I will be referred for an examination or that I will be accepted as a patient following an examination. I understand that Dental Lifeline Network·• Montana, which coordinates the DDS program, will determine whether I am eligible for the program and, if so, will try to refer me to a participating volunteer dentist. I further understand that the dentist, not the organization, is solely responsible for diagnosis and any possible treatment that I might receive for my dental needs. b. I understand that the dentist(s) has volunteered to treat my existing dental condition only and is not obligated to provide donated care in the future or to maintain me as a patient. c. I understand that a volunteer dentist in the DDS program may discontinue providing services to me at any time upon reasonable notice provided to me. I understand that, after receiving such notice, I am responsible for obtaining the services of an alternate dentist. I also understand that the Dental Lifeline Network·• Montana has no responsibility to assist me in obtaining the services of an alternate dentist. 3. My Responsibilities
I understand the importance of keeping all scheduled appointments and agree to make them.
To the best of my knowledge, the information provided on this form is a full and accurate disclosure of my current
physical, medical, and financial status.

Signature of client:
Signature of client's guardian (if necessary):
4. Optional Photo and Information Consent Form
I authorize Dental Lifeline Network·• Montana to use my name, information, statements, or photograph for public relations
purposes, and to attribute my statements to me as an expression of my personal experience. I understand that this
information may be used in dental journals, website(s), media articles, advertisements or other marketing materials that
promote the programs of the organization and encourage involvement from dental professionals and funders. I also agree
that no material needs to be submitted to me for any further approval, and I give the organization the right to copyright
such material if necessary. I understand that if I don't grant this permission, it will not affect my eligibility for receiving
services through Donated Dental Services (DDS).

Signature of client:
Signature of client's guardian (if necessary): Page 4 of 5
I, _____________________________________ Authorize Dental Lifeline Network • Montana to obtain information from and share information with: ______________________________________________________________________________ Name of Medical Provider/Hospital/Person/Agency Address City, State, Zip Client is seeking care through the Dental Lifeline Network • Montana (DLN) Donated Dental Services (DDS) program, a humanitarian initiative through which volunteer dentists and laboratories provide comprehensive dental care without charge for individuals with mental, physical, and/or medical disabilities. Information about the Client will be used to better understand the relative clinical circumstances and needs of applicant, and the possible medical necessity and urgency for dental treatment. Please print clearly.
• I understand and authorize the release of medical and personal information about me for purposes of receiving comprehensive dental treatment through the DDS Program. • I understand that if I do not sign this authorization that DLN may withhold treatment or eligibility for the DDS • I understand that there is potential for information disclosed, as a result of this release/authorization, to be re- disclosed by the recipient and therefore no longer protected by the HIPAA Privacy Regulation. • I understand that I may revoke this release/authorization at any time by giving written notice to DLN, except to the extent that action has already been taken to comply with it. Without such revocation this release/authorization will expire on _____/______/______, or if left blank, one year from the date of my signature. Any revocation of authorization will prevent me from further treatment through the DDS program. • I understand that I have a right to refuse to sign this form subject to the conditions noted above or if I sign I am ______________________________________________ Signature of Client/Legal Representative ________________________________________________ NOTICE TO WHOM THIS INFORMATION IS GIVEN: this information has been disclosed to you from records
whose confidentiality is protected by Federal law. Federal Law prohibits you from making further disclosure of
this information without the specific written consent of the person to whom it pertains. If applicable, an
assessment of the minimum necessary amount of information required has been applied to this
DO NOT sign below unless you wish to revoke your consent for release of information.
I hereby revoke this Consent to Release/Authorization for Information.
______________________________________________ Signature of Client/Legal Representative Page 5 of 5



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