Application

APPLY TODAY!

If you need dental help and meet the qualifications, please complete the form below.

If you need to know more information about eligibility and process, please see this page.

Estimated time: Approximately 15-20 minutes

As part of your application, you may need to submit a few additional forms. The forms below can be submitted at a later date.

DD-214;
Medical Documentation;
Proof of Disability.

Address

(Required)

Address

Street Address County City State ZIP Code

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Select your state:

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Bibb
Pickens

Due to lengthy waitlists, all counties are CLOSED to new applications.

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Arkansas
Benton
Bradley
Carroll
Clark
Crawford
Dallas
Franklin
Garland
Hempstead
Howard
Logan
Madison
Montgomery
Poinsett
Union
Washington

Due to lengthy waitlists, all counties are CLOSED to new applications.

We are NOT accepting applications in the following counties. If your county is listed, we cannot accept your application at this time.

Alamosa
Bent
Huerfano
Rio Grande
San Miguel
Sedgwick
Yuma

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Litchfield

Due to lengthy waitlists, all counties are CLOSED to new applications.

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Alachua
Collier
Highlands
Lake
Sumter

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Baldwin
Barrow
Bibb
Bryan
Bulloch
Burke
Camden
Chatham
Chattahoochee
Clayton
Cobb
Columbia
Crawford
DeKalb
Dougherty
Douglas
Effingham
Evans
Fayette
Forsyth
Fulton
Glascock
Glynn
Gwinnett
Hall
Harris
Henry
Houston
Jefferson
Jones
Lamar
Liberty
Lincoln
Macon
Marion
McDuffie
Monroe
Muscogee
Newton
Oconee
Paulding
Peach
Richmond
Rockdale
Stewart
Talbot
Taylor
Tift
Twiggs
Upson
Warren
Wilkinson
Worth

Due to lengthy waitlists, new applications are NOT being accepted from the following islands. If your island is listed, we cannot accept your application at this time.

Kauai
Maui

On the Big Island we are ONLY accepting applications in the following cities. If your city is not listed, we cannot accept your application at this time.

Honokaa
Kailua-Kona
Kealakekua
Waimea (or Kamuela)

Due to lengthy waitlists, new applications are NOT being accepted from the following counties. If your county is listed, we cannot accept your application at this time.

Kootenai

Due to lengthy waitlists, new applications are NOT being accepted from the following counties. If your county is listed, we cannot accept your application at this time.

Adams
Alexander
Franklin
Gallatin
Hamilton
Hancock
Hardin
Jefferson
Johnson
Massac
McDonough
Pope
Pulaski
Union
Wayne
Williamson

We are NOT accepting applications in the following counties. If your county is listed, we cannot accept your application at this time.

Clark
Floyd
Harrison
Jackson
Jefferson
Lawrence
Madison
Miami
Monroe
Morgan
Pike
Ripley
Scott
Vanderburgh
Warrick
Washington
Wayne

All counties are OPEN to new applications.

We are NOT accepting applications in the following counties. If your county is listed, we cannot accept your application at this time.

Allen
Cherokee
Cheyenne
Crawford
Ellsworth
Franklin
Kiowa
Marion
Mitchell
Morris
Norton
Pawnee
Riley
Rooks
Russell
Sherman
Smith

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Allen
Adair
Barren
Bullitt
Butler
Cumberland
Edmonson
Fayette
Grayson
Hardin
Hart
Henry
Jefferson
Larue
Madison
Meade
Metcalfe
Monroe
Nelson
Oldham
Scott
Shelby
Simpson
Spencer
Taylor
Trimble
Warren

We are ONLY accepting applications in the following parishes. If your parish is not listed, we cannot accept your application at this time.

Caddo
East Baton Rouge
Jefferson
Lafourche
Orleans
St. Bernard
St. James
St. Martin
St. Tammany
Tangipahoa
Terrebonne
West Baton Rouge

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Androscoggin
Cumberland
Knox
Oxford
Piscataquis
Sagadahoc
Somerset
Waldo
York

All counties are OPEN to new applications.

We are currently accepting applications in the following counties:

Barnstable
Berkshire
Bristol
Dukes
Franklin
Hampshire
Nantucket
Plymouth

All counties are OPEN to new applications.

We are NOT accepting applications in the following counties. If your county is listed, we cannot accept your application at this time.

Anoka
Carver
Cook
Cottonwood
Dakota
Freeborn
Isanti
Koochiching
Lake of the Woods
Mower
Pine
Ramsey
Sherburne
Stearns
Washington

Due to lengthy waitlists, all counties are CLOSED to new applications.

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Boone
Cape Girardeau
Christian
Clay
Clark
Clinton
Cole
Franklin
Greene
Henry
Jasper
Johnson
Knox
Laclede
Livingston
Marion
Miller
Newton
Osage
Pettis
Phelps
Platte
Pulaski
Randolph
Ray
Scotland
St. Charles
St. Louis
St. Louis City
Taney
Vernon

We are NOT accepting applications in the following counties. If your county is listed, we cannot accept your application at this time.

Custer

Due to lengthy waitlists, all counties are CLOSED to new applications.

Due to lengthy waitlists, all counties are CLOSED to new applications.

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Grafton
Carroll
Cheshire
Coos
Hillsborough
Merrimack
Rockingham

We are NOT accepting applications in the following counties. If your county is listed, we cannot accept your application at this time.

Ocean County

All counties are OPEN to new applications.

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Albany
Allegany
Erie
Fulton
Genesee
Herkimer
Livingston
Madison
Oneida
Onondaga
Putnam
Rensselaer
Saratoga
Schenectady
Tompkins
Warren
Washington
Westchester
Wyoming

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Buncombe
Carteret
Gaston
Mecklenburg
Moore
Randolph

We are NOT accepting applications in the following counties. If your county is listed, we cannot accept your application at this time.

Benson
Bottineau
Cass
Dickey
Emmons
Morton
Sargent
Ward

Due to lengthy waitlists, all counties are CLOSED to new applications.

Due to lengthy waitlists, all counties are CLOSED to new applications.

We are NOT accepting applications in the following counties. If your county is listed, we cannot accept your application at this time.

Crawford
Erie

All counties are OPEN to new applications.

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Florence
Pickens

All counties are OPEN to new applications.

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Anderson
Cocke
Greene
Knox
Madison
Maury
Montgomery
Shelby
Rutherford
Warren

Due to lengthy waitlists, all counties are CLOSED to new applications.

All counties are OPEN to new applications.

We are ONLY accepting applications in the following counties. If your county is not listed, we cannot accept your application at this time.

Bennington

We are NOT accepting applications in the following counties. If your county is listed, we cannot accept your application at this time.

Arlington
Culpepper
Fairfax
Fauquier
Greene
Loudoun
Madison
Orange

We are NOT accepting applications in the following cities. If your city is listed, we cannot accept your application at this time.

Alexandria
Fairfax
Falls Church
Fredericksburg
Manassas

Due to lengthy waitlists, all counties are CLOSED to new applications..

Due to lengthy waitlists, all counties are CLOSED to new applications.

We are NOT accepting applications in the following counties. If your county is listed, we cannot accept your application at this time.

Berkeley
Calhoun
Doddridge
Gilmer
Grant
Greenbrier
Hampshire
Hardy
Jefferson
Logan
Mineral
Mingo
Pendleton
Pleasants
Pocahontas
Ritchie
Taylor
Tucker
Tyler
Wirt
Wood

Due to lengthy waitlists, all counties are CLOSED to new applications.

We are ONLY accepting applications in the following counties. If your county is NOT listed, we cannot accept your application at this time.

Park
Sweetwater
Teton
Uinta
Washakie

Eligibility Information

(Required)

Please check one or more of the below options that applies to you:(Required)

Over 65 years of age

Permanently disabled

Has medical documentation that dental care is required

None of the above

According to eligibility requirements, you do not seem eligible for the DDS program. Please go to your state’s dental association to receive a list of public dental assistance and sliding scale clinics. You may also search for a community health center near you that offers dental care by going to https://findahealthcenter.hrsa.gov/

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Are You a Military Veteran?

Yes