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DLN Application
DLN Application
"
*
" indicates required fields
1
Information and Referral Agency
2
Medical and Dental information
3
Income, Financial Assistance, Expenses
4
DLN agreement, ROIs and Photo consent
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.
*
Required fields
First Name
*
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
Please fill in the zip code and make sure the city and state appear
County of Residence
*
Phone Number
*
Email
Date of Birth
*
Month
Day
Year
Hidden
Age
Hidden
Age
Sex at Birth
*
Male
Female
Other
Gender
*
Male
Female
Transgender
Non-Binary/Non-Conforming
Other
Pronouns
Race
*
White
Black
American Indian/Alaskan Native
Asian
Native Hawaiian/Pacific Islander
LatinX
Prefer not to answer
Other
Marital Status
*
Single
Married
Divorced
Widowed
Separated
Military Veteran
*
Yes
No
*If you selected "Yes", please send a copy of your DD-214 to your respective coordinator. Their contact information can be found after you submit this application.
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?
*
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
State
How did you hear about the DDS program?
Internet
Friends
Family
Other
In what website?
Referring Agency
Are you referred by an agency or have a caseworker/social worker with an agency, non-profit or hospital?
*
Yes
No
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.
*
Required fields
Primary Physician's Name
*
Primary Physician's Phone Number
*
Please check all that apply. If you check any of these, please have our triage form completed by your medical doctor:
Please check all that apply. If you check any of these, 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.
Major Disabilities or Health Problems
*
Please include any health conditions you currently see a doctor or take medications to treat. 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
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.
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?
By car
By bus
By cab
Other
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.
*
Required fields
Does anyone live with you?
*
Yes
No
List the people that live with you (Name, Age, Relationship to You, and Monthly Income of Each Person in the Household):
Name
Age
Relationship
Income
Add
Remove
Press the "+" sign to add a new person
Total monthly income of other household members, not including you:
*
Please enter a number greater than or equal to
0
.
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
.
Child Support:
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.
*
Required fields
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
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
Child Care
Do you have any cars in your household?
*
Yes
No
Please provide the make, model and year of each car.
*
Make
Model
Year
Add
Remove
Press the "+" sign to add a new car
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.
*
Required fields
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.
*
1. Agreement - Release of Information:
I understand that I will need to provide personal information that includes but, is not limited to medical, dental, and financial condition. I authorize Dental Lifeline Network (DLN) 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 programs at DLN.
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 DLN to share information with and obtain information about me with one or more DLN dentist(s) volunteering through the program.
I understand if my disability is AIDS or HIV related, I authorize DLN to release information about my AIDS or HIV-related medical condition to one or more DLN volunteer dentists in the program and hold DLN 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 at either the termination or completion of my treatment through programs at DLN.
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.
*
2. Eligibility and Treatment Understanding:
I realize that my application to DLN 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 DLN 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 may receive for my dental needs.
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.
I understand that DLN volunteer dentists may discontinue providing services to me at any time. I understand that I am responsible for obtaining the services of an alternate dentist. I also understand that DLN 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.
*
3. My Responsibilities:
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.
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/cancel more than one appointment, I may be terminated from receiving services through DLN.
I shall not ask DLN volunteer dentists 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 the dentist’s discretion.
I Agree
To certify your application, please provide an electronic signature (type your full name).
*
Optional Photo and Information Consent Form
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 Dental Lifeline Network (DLN).
I Agree
Please provide an electronic signature (type your full name) to authorize use of your photo or information as described.
Email
This field is for validation purposes and should be left unchanged.
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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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