Each child needs to have a registration packet and consent form completed by their guardian in order to be seen on the Tooth Mobile.
On the Tooth Mobile, each child will receive a cleaning, exam, x-rays, and fluoride varnish. If any urgent or emergent needs are discovered, additional treatments to include tooth extractions may be completed. Dental services such as silver crowns and fillings may need to be completed at a Charles Drew Health Center site. After every visit, the child will receive a postcard that should be taken home that explains what services were provided at the visit and if there are any follow-up instructions that the guardian should be aware of.
While the services are not free, Charles Drew Health Center accepts Medicaid and many insurance plans. In the event your child does not have insurance, Charles Drew Health Center has established a team of certified application counselors to aid in enrolling your child with dental insurance and would be happy to explore those options. If our team of eligibility and enrollment specialists finds that your child is ineligible for dental insurance or does not qualify for Medicaid benefits, Charles Drew Health Center offers a Sliding Fee Discount Program to help with out of pocket costs.
If a child is covered by insurance, Charles Drew Health Center must first seek reimbursement for costs from the insurance carrier.
The Tooth Mobile is intended to reach the community as an outreach opportunity and on a periodic basis. Charles Drew Health Center would be proud to serve as your child’s primary dental provider and he/she can be seen at any of our dental locations. Please call 402.451.3553 to schedule an appointment.
An attempt will be made to complete all necessary dental treatment on the Tooth Mobile. However, the child’s comfort level may not warrant completion of treatment on the Tooth Mobile or the dental needs may be such that the child would benefit from treatment in a traditional dental setting. In these instances, a member of our staff will reach out to schedule an appointment for the child at a Charles Drew Health Center location.
The Tooth Mobile is a program of Charles Drew Health Center, Inc. designed to help children receive needed dental preventative and treatment on-site, while at school. If you already have a dentist, we encourage you to see them regularly for routine care.
Please initial each line:
I want my child to receive a DENTAL EXAM and NECESSARY DENTAL TREATMENT. I hereby authorize Charles Drew Health Center, Inc. to examine and treat my minor child or ward, and to perform procedures, including but not limited to: cleaning, fluoride varnish, sealants, x-rays, fillings, silver crowns, and extractions (some may require local anesthesia), as necessary by the dentist. I authorize payment of dental insurances to include Medicaid benefits directly to Charles Drew Health Center, Inc. I authorize Charles Drew Health Center, Inc. to share my dental record and to share the record with any specialty care provider that may be needed in the course of my care.
NOTICE OF PRIVACY PRACTICES I understand the Notice of Privacy Practices of Charles Drew HealthCenter, Inc. is available at my child’s school. I have had full opportunity to read and consider the contents of theNotice of Privacy Practices. I understand that I have the right to revoke this consent at any time by giving written notice and that my revocation could result in the discontinuance of treatment by Charles Drew Health Center, Inc. I further understand that Charles Drew Health Center, Inc. reserves the right to change the Notice of Privacy Practices as they have been described. If the Notice of Privacy Practices is revised, the new Notice of Privacy Practices will be issued to the school and available to me. Those changes may also apply to any of the protected health information.
EMERGENCIES If a medical emergency should occur, the mobile unit may call the school and 911 and emergency fees may be assessed to the patient.
MEDIA RELEASEI understand that my child may be photographed directly or indirectly while participating with this program. I understand that the purpose of such media is for advertisement and promotion of the mobile dental clinic program. I give permission by initialing for the photos to be reproduced and printed for such purposes.
TREATMENT AT CHARLES DREW HEALTH CENTER, INC.I understand that if I choose to bring my child to Charles Drew Health Center, Inc., there may be a fee for services provided. Charles Drew Health Center, Inc. dental clinic accepts Medicaid and many insurance plans. In the event that my child does not have insurance or qualify for Medicaid benefits, I understand the Charles Drew Health Center, Inc. offers a sliding fee scale program, based on family size and household income.
Available and appropriate care and treatment services offered to patients solely on the basis of condition without differentiation or consideration of: race, age, sex, disability, national origin, religion, sexual orientation, gender identity, immigration status, or ability to pay.
I authorize release of information regarding continuation of care and/or any payments for services. I authorize a copy of this document may be used as the original document. I certify all information provided is true and accurate to the best of my knowledge.
Please answer each question for the patient and provide additional information when required:
FOR WOMEN PATIENTS ONLY:
Is the patient taking any of the following?
Is the patient allergic or has the patient adversely reacted to any of the following?
Please indicate any history of the following:
I understand the importance of a truthful and complete Health History to assist my dentist in providing the best care possible. If there are any changes in my health, or medicines, I will inform my dentist at my next appointment.
Charles Drew Health Center, Inc. defines family size as the total number of members in the patient or guarantor’s household. Household members may include self, spouse, dependents, or anyone within the residence for which the head of household provides monetary support.
Charles Drew Health Center, Inc. defines income as earnings over a period of time, usually annually, used to support the patient or household. Examples of proof of income sources include: most recent tax returns, most recent paycheck stub(s),or statement of income determination for federal, state, or local government.
Note: The below table does not determine eligibility, but allows Charles Drew Health Center, Inc. to assess your qualification for other financial assistance.
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I certify the information given on this form and the provided income documentation is complete, true, and correct to the best of my knowledge. If I do not qualify for financial assistance, I agree to pay the outstanding balance in full. I agree and understand that financial assistance may not apply to all of the services provided at Charles Drew Health Center, Inc. If account balances are not paid, I agree to pay the resulting collection charges, legal fees, and understand access to CDHC services may be terminated. I understand I will be required to reapply by submitting a new Financial Assistance Application if my income changes prior to the expiration date below or if my income changes.
I choose not to disclose income or opt-out and therefore choose not to participate in the Sliding Fee Discount Program. I understand that I will be charged full fee for all services and will not be eligible for any discounts.
Charles Drew Health Center, Inc. requires patients or guarantors to provide documentation of income to be eligible to participate in the Sliding Fee Discount Program. Charles Drew Health Center, Inc. defines income as earnings over a period of time, usually annually, used to support the patient or household.
Please answer the following questions and provide additional information when required:
I certify the information given on this form is complete, true, and correct to the best of my knowledge. If found to be untruthful, I understand access to CDHC services may be terminated. I understand I will be required to reapply by submitting a new Financial Assistance Application if my income changes.
Please note that for privacy reasons, we are unable to respond via email to questions regarding specific health concerns.