Government of the District of Columbia School Based Oral Health Program Consent Form

Government of the District of Columbia School Based Oral Health Program Consent Form
The District of Columbia Department of Health (DC Health) sponsors preventive dental services at your child’s school/ facility through the DC School-Based Oral Health Program (SBOHP Through this program, licensed dentists and their staff provide exams (“checkups”) and x-rays to students who have not seen a dentist in six (6) months. The services include dental cleanings, fluoride treatments, and sealants (as needed Children who may need additional services such as fillings, drillings, shots, tooth removal, or braces, will be referred to their dental homes. Information from your child’s visit will be shared with the appropriate point of contact at the school/facility, and with the SBOHP for the purposes of follow-up, and program monitoring.

PLEASE NOTE: Children should see their dentists every six (6) months. The SBOHP services should NOT take the place of a visit to a child’s regular dentist. The dental providers will check for dental insurance coverage and the last dental visit for all children to be seen at the school/facility and will bill insurance for any services provided.
CHILD/STUDENT INFORMATION
Child Name*
Date of Birth (MM/DD/YY)*

MonthDayYear
Date
Current Gender Identity
Home Address (Street, City, State, Zip Code)
School/Facility Name*
Grade
Teacher Name
Parent/Guardian Name*
Phone Number*
Format: (000) 000-0000.
Alternate Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Last Dental Visit:
Last Dental Visit:4–6 Months ago6+ Months agoUnsureNever
Primary Dental Provider
HEALTH INSURANCE
This child has the following Medicaid/Health Families insurance plan:
DC Healthy FamiliesDC MedicaidAmeriHealth CaritasMedStar Family ChoiceAmeriGroup (CareFirst)Health Services for Children with Special NeedsOther
DC Medicaid ID Number:
This child has private dental insurance:
Insurance Company
Insurance Co. Phone
Format: (000) 000-0000.
Employer
Employer Phone
Format: (000) 000-0000.
Name of Insured Adult
Insured Adult’s Date of Birth

MonthDayYear
Date
Member ID/Policy #
Group #
This child does not have any dental insurance
Government of the District of Columbia School Based Oral Health Program Consent Form
- As the parent/guardian of the above-named student, I consent for him/her to receive dental services through the DC Health School-Based Oral Health Program. I understand that my child’s participation provides consent for the following:
- The dental provider to verify insurance before services are provided.
- The dental provider to bill & collect payment from any Medicaid, private insurance, or other payer.
- If I have private dental insurance, the dental provider to bill the family for any deductibles and/or copays.
- The dental provider to confidentially share my child’s clinical information with DC Health, DC Department of Health Care Finance, Medicaid Managed Care Organizations, and/or other clinical providers involved in my child’s health care.
Further, I agree to discharge, indemnify, and hold harmless the Government of the District of Columbia and any agency, employee, officer, agent or representatives thereof from all claims, demands, actions, or judgments which I or my heirs, executors, administrators, or designees may have for any and all injuries and damages, known or unknown, caused by or arising from the activities listed above. I understand that if I fail to sign this consent form, my child will

not receive any services offered under this program.

I understand I may revoke this consent at any time by providing written notice to DC Health’s Oral Health Program (899 N. Capitol St. NE, 3rd Floor, Washington, DC 20002) or via email hcab.dchealth@dc.gov. I further understand that

until this revocation is made, the consent for services shall remain in effect for one calendar year from the date it is signed, and my child’s information will continue to be accessible by the parties listed above for the specific purposes described.

Please provide the following information to help the dental provider best serve your child:
MEDICAL INFORMATION
Dental Problems
Please explain any dental problems your child may be experiencing
Heart problems/valve replacements/shunts
Please explain any heart problems your child may be experiencing
Asthma/breathing problems
Asthma/breathing problems
Epilepsy/seizures
Epilepsy/seizures
Antibiotics premedication required
Please list any antibiotics premedication required
Current medications
AllergiesLatex allergyPine nut allergyAcrylic allergyOther
Other health problems diabetes, bleeding problems, communicable diseases, etc
Please explain any other health problems your child may be experiencing
Child’s Primary Care Doctor and/or Provider (if applicable)
Child’s Primary Care Doctor and/or Provider (if applicable)
I have read the notice on this page and understand and agree to its terms. By signing, I give my informed consent for my child to receive services through the DC Health School-Based Oral Health Program.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
899 North Capitol Street NE, 3rd Fl | Washington, DC 20002 | p 202-442-5925 | f 202-442-2927 | dchealth.dc.gov
Should be Empty:

Government of the District of Columbia School Based Oral Health Program Consent Form

CHILD/STUDENT INFORMATION

Last Dental Visit:

HEALTH INSURANCE

Government of the District of Columbia School Based Oral Health Program Consent Form

MEDICAL INFORMATION