Donated Dental Services Application | Dental Lifeline Network

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1Information and Referral Agency

2Medical and Dental information

3Income, Financial Assistance, Expenses

4DLN agreement, ROIs and Photo consent

Agreement

Please read the following statements. If you understand and agree to the conditions, please sign and date at the bottom of the form.

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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.

Comments

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Contact

Dental Lifeline Network
1800 15th Street, Suite 100
Denver, CO 80202

Phone: 303.534.5360
Fax: 303.534.5290

DLN Application

Applicant Information

Referring Agency

Medical Information

Dental Information

Household Financial Information

Financial Assistance

Monthly Household Expenses

Agreement

Optional Photo and Information Consent Form