BMDC New Patient Application V2024

New Patient Application

Ben Massell Dental Clinic
Eligibility Screening Information
Please read the following carefully.

The Ben Massell Dental Clinic is a free dental clinical for adults who qualify based on income and other criteria. We are a volunteer dental care clinic protected by state-sponsored, Sovereign Immunity. Makeing false statements or representations on this form may be punishable under Georgia law by a fine, imprisonment, or both.

We do not offer emergency or walk-in services.
To qualify for services, the patient must:
- Live in one of the following 13 counties for at least six (6) months:
  - Butts
  - Cherokee
  - Clayton
  - Cobb
  - Coweta
  - DeKalb
  - Douglas
  - Fayette
  - Fulton
  - Gwinnett
  - Henry
  - Paulding
  - Rockdale
- Show proof of county residence, such as a utility bill
- Have no insurance to cover dental costs
- Have a total household income at or below 125% of the current poverty level
Financial Eligibility Worksheet
Please list all the dependent members of your household and their sources of income. Include spouses, children under 18, or fulltime students between ages 18 and 21, and legally dependent disabled adult.
Self
Initials (self)*
Date of Birth (self)*

MonthDayYear
Date
Source of Income (self)*
Monthly amount (before taxes) (self) $*
Household Dependent #1 (if applicable)

(HD1)
Initials (HD1)
Date of Birth (HD1)

MonthDayYear
Date
Relationship to patient (HD1)
Source of Income (HD1)
Monthly Amount (before taxes) (HD1) $
Household Dependent #2 (if applicable)

(HD2)
Initials (HD2)
Date of Birth (HD2)

MonthDayYear
Date
Relationship to patient (HD2)
Source of Income (HD2)
Monthly Amount (before taxes) (HD2) $
Household Dependent #3 (if applicable)

(HD3)
Initials (HD3)
Date of Birth (HD3)

MonthDayYear
Date
Relationship to patient (HD3)
Source of Income (HD3)
Monthly Amount (before taxes) (HD3) $
Household Dependent #4 (if applicable)

(HD4)
Initials (HD1)
Date of Birth (HD4)

MonthDayYear
Date
Relationship to patient (HD4)
Source of Income (HD4)
Monthly Amount (before taxes (HD4) $
Total household monthly income from all sources listed above (before taxes): $
Number of dependent persons living in the home (including yourself):
Number of dependent children under age 18 years:
Number of dependent full-time students between ages 18 and 21 years:

Review the chart below to determine eligibility.

Family Size	Monthly Income (125% of 2024 Federal Poverty Guidelines)
1	$1,569
2	$2,129
3	$2,690
4	$3,225
5	$3,810
6	$4,371
7	$4,931
8	$5,492

Please validate the following to determine if you are eligible to continue with the application.
I verify that I live in one of the 13 counties listed above.*

YesNo
I can show proof of county residence.*

YesNo
I verify that I have no insurance to cover dental costs.*

YesNo
I tentatively meet the financial eligibility requirements listed above.*

YesNo

New Patient Application

Eligibility Screening Information

Financial Eligibility Worksheet

Self

Household Dependent #1 (if applicable)

Household Dependent #2 (if applicable)

Household Dependent #3 (if applicable)

Household Dependent #4 (if applicable)

Patient Information

Documentation to submit