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Veteran Application
Veteran Application
"
*
" indicates required fields
1
Information and Referral Agency
2
Medical and Dental information
3
Income, Financial Assistance, Expenses
4
The agreement, ROIs and Photo consents
Applicant Information
Please fill out this information to the best of your ability. If you are unable to answer a required question type NONE or 0 for your answer.
Are You a Military Veteran?
*
Yes
No
*Please send a copy of your DD-214 to your respective coordinator. Their contact information can be found after you submit this application.
What branch of the military did you serve in?
Army
Navy
Marine Corps
Air Force
Coast Guard
This form is for veterans to apply for donated dentistry. If you are not a veteran, please visit your state page to apply:
Return to state page selection
First Name
*
Middle Initial
Last Name
*
Address
*
Street Address
Apartment, unit, etc.
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
County of Residence
*
Phone Number
*
Email
Date of Birth
*
Month
Day
Year
Hidden
Age
Hidden
Gender
Female
Male
Gender
*
Male
Female
Transgender
Non-Binary/Non-Conforming
Sex at Birth
*
Male
Female
Other
Pronouns
Race
*
White
Black
American Indian/Alaskan Native
Asian
Native Hawaiian/Pacific Islander
LatinX
Prefer not to answer
Hidden
Marital Status
Single
Married
Divorced
Widowed
Separated
Marital Status
*
Single
Married
Divorced
Widowed
Separated
Contact Person Name
*
First Name
Last Name
Contact Person's Phone
*
Contact Person's Relationship to You
Have you received services through the Donated Dental Services (DDS) program before?
*
Yes
No
If yes, in which state?
*
How did you hear about the DDS program?
Referring Agency
If you were not referred by an agency or do not have a caseworker/social worker with an agency, non-profit or hospital, please put NONE under "Name of Agency."
Name of Agency
*
Name of Caseworker
Caseworker's Phone Number
Agency or Caseworker Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Medical Information
Please fill out this information to the best of your ability. If you are unable to answer a required question type NONE or 0 for your answer.
Primary Physician's Name
*
Primary Physician's Phone Number
*
Please check all that apply. If you check any of these boxes, please have our triage form completed by your medical doctor.
I have a artificial heart valve and/or stent
I receive treatment for heart problems
I am currently on dialysis
I have Crohn's disease
I have had an organ transplant
I am currently being treated for cancer
I have osteoporosis
I have rheumatoid arthritis
I have Lupus
I have Multiple Sclerosis
I take Clozaril
I have an artificial joint or other orthopedic hardware
Have you taken any of the following medications?
Boniva
Prolia
Fosamax
Reclast
Actonel
Interferon
*If you checked any of these, please take our triage form to your doctor and have them fill it out. Please then send it to your respective coordinator. The link to the form and the coordinator's information will be made available after you submit this application.
Major Disabilities or Health Problems
*
Please include any health conditions you currently see a doctor or take medications for. Be as specific as possible.
Do you use a:
Wheelchair
Cane
Walker
Scooter
None
Do you require wheelchair access?
Yes
No
N/A
Dental Information
Briefly describe your dental problems:
*
How many natural upper teeth do you have remaining?
Please enter a number greater than or equal to
0
.
How many natural lower teeth do you have remaining?
Please enter a number greater than or equal to
0
.
Approximate Date of Last Dental Visit
Name of Last Dentist:
Last Dentist's Phone Number
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:
Household Financial Information
Please fill out to the best of your ability. If you do not know an exact amount, enter your best estimate. If you are unable to answer a required question type NONE or 0 for your answer.
Does anyone live with you?
*
Yes
No
How Many People?
*
Name of Each Person, Age, Relationship, and Monthly Income in Your Household:
Total monthly income of other household members, not including you:
*
Are you able to work?
*
Yes
No
If no, please explain why:
*
If you are employed, place of employment:
*
Your Monthly Employment Income:
*
Please enter a number greater than or equal to
0
.
Is your spouse/significant other employed?
*
Yes
No
I don't have a spouse/significant other
If no, please explain why:
*
If they are employed, place of employment:
Spouse/Significant Other's Monthly Employment Income:
*
Please enter a number greater than or equal to
0
.
Financial Assistance
Please fill out to the best of your ability. If you are unable to answer a required question please type 0 for your answer.
Please mark any financial assistance that you (the applicant) receive:
*
SSI or SSDI Payments
Social Security (Retirement)
Unemployement/Workers Compensation
Temporary Assistance to Needy Families (TANF)
None
Other
*If you checked "SSI or SSDI Payments", please send a copy of your award letter or proof of disability to your respective coordinator. Their contact information can be found after you submit this application.
Applicant's SSI or SSDI Payments
*
Monthly Amount
Social Security (Retirement)
*
Monthly Amount
Unemployment/Workers Compensation
*
Monthly Amount
Temporary Assistance to Needy Families (TANF)
*
Monthly Amount
Other Public Assistance:
*
Please provide any other public assistance not listed and the monthly amount you receive.
If you chose NONE, please explain:
*
Total Monthly Household Income
*
If you are not receiving disability, have you ever applied?
*
Yes
No
N/A
Please mark each that applies to you:
*
Savings
Pension
Investments/Assets
Food Stamps
None
Total Value of Savings
*
Amount of Pension
*
Type of Investments/Assets
*
Total Value of Investments/Assets
*
Monthly Amount in Food Stamps
*
If you chose NONE, please explain:
*
Do you receive Medicaid benefits?
*
Yes
No
Do you receive Medicare benefits?
*
Yes
No
Do you have a Medicare Advantage Plan?
*
Yes
No
Do you have dental insurance?
*
Yes
No
*If you selected "Yes", please send a copy of your dental benefits to your respective coordinator. Their contact information can be found after you submit this application.
Name of Dental Insurance
Monthly Household Expenses
Please fill out to the best of your ability. If you do not know an exact amount, enter your best estimate. If you are unable to answer a required question type NONE or 0 for your answer. Please provide your MONTHLY expenses in the following categories:
Own or Rent?
*
Own
Rent
How much is your monthly mortgage payment?
*
Please enter a number greater than or equal to
0
.
How much is your monthly rent?
*
Please enter a number greater than or equal to
0
.
Food (not including Food Stamps)
*
Utilities
*
Phone
*
Cable/Internet
*
Credit Card/Loan Payments
*
Medications/Medical Cost
*
Out of Pocket Health Insurance
*
Life/Burial Insurance
Do you have any cars in your household? Please provide the make, model and year of each car.
*
Put NONE or 0 if you have no cars.
Car Payment Total
*
Please enter a number greater than or equal to
0
.
Car Insurance/Car Expense/Gas
*
Other Monthly Expenses
Total Monthly Household Expenses
*
Are any family members able to contribute to costs of your dental treatment?
*
Yes
No
If yes, please explain:
*
Are any other sources available to help pay for dental care?
*
Yes
No
(i.e. churches, service organizations, other agencies, etc?)
If yes, please explain:
*
Additional Information
Use this area to add any other information you would like to share with us.
Agreement
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 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 harmless for doing so. d. 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 at either the termination or completion of my treatment through the DDS program.
*
I Agree
2. Eligibility and 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, 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 has no responsibility to assist me in obtaining the services of an alternate dentist.
*
I Agree
3. My Responsibilities: a. I agree to find and obtain reliable transportation to and from all dental appointments. Also, I agree to arrive on time to all of my appointments and will make every effort to arrive 15 minutes early prior to the time of my appointment. b. I agree to keep all appointments unless I have a serious emergency and rescheduling is unavoidable. If I have an emergency and I am unable to keep an appointment, I will follow the dentist's policy regarding cancellation and call the dentist's office to cancel my appointment at least 24-48 hours in advance. I understand that if I miss an appointment without calling in advance or reschedule or cancel more than one appointment, I may be terminated from the DDS program. c. I shall not ask the DDS volunteer dentist for pain medication and understand that medications will only be supplied or prescribed to me by the dentist when it is absolutely necessary and at their discretion and at the dentist’s discretion. To the best of my knowledge, the information provided in this application is a full and accurate disclosure of my current physical, medical, and financial status and I agree to the terms and conditions stated above.
*
I Agree
To certify your application, please provide an electronic signature (type your full name).
*
4. Optional Photo and Information Consent Form: I authorize Dental Lifeline Network 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).
I Agree
I Disagree
Please provide an electronic signature (type your full name) to authorize use of your photo or information as described.
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Dental Lifeline Network
1800 15th Street, Suite 100
Denver, CO 80202
Phone: 303.534.5360
Fax: 303.534.5290
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