Community Resource Agency (CRA) Agreement Form

DentMed, Inc. is a 501(c)(3) nonprofit organization based in Maryland dedicated to improving access to quality healthcare in underserved communities. The organization identifies areas with significant gaps in healthcare access and coordinates the delivery of free pop-up clinics for residents of those communities and surrounding regions. DentMed,Inc. provides comprehensive dental, vision, and medical services at no cost to patients, with a focus on reducing barriers to care and promoting overall community health. In addition to clinical services, DentMed, Inc. supports community engagement through the distribution of educational resources and the facilitation of live training and outreach programs for underserved youth and adults. All services and programs are delivered in alignment with the organization’s core values of compassion, respect, and integrity. 

The Community Resource Agency agrees to uphold the mission of DentMed, Inc. and will not charge any individuals at the pop-up clinic for services, materials, or goods provided on-site.

The Community Resource Agency acknowledges that DentMed,Inc. and its affiliates do not own, operate, or maintain pop-up medical clinic venues and agrees that its participation in and association with DentMed, Inc.at any such clinic is entirely voluntary. In consideration for being permitted to participate as a community resource, the Community Resource Agency, on behalf of itself and its representatives, employees, agents, officers, directors, volunteers, affiliates, successors, and assigns, hereby knowingly and expressly waives and releases any and all claims, whether known or unknown, against DentMed, Inc. and its officers, directors, employees, agents, affiliates, host organizations, volunteers, successors, and assigns (collectively, the “Releasees”), arising out of or related to injury, death, or property damage connected to its participation in the pop-up clinic, including claims arising from the negligence of DentMed, Inc., any Releasee, or any third party. The Community Resource Agency further agrees not to assert or bring any such claims and irrevocably releases and discharges DentMed, Inc. and all Releasees from any liability related thereto.

The Community Resource Agency agrees that any property damage to the venue or such other location as is selected by DentMed, Inc. or its Releasees as a result of negligent or intentional misconduct by the Community Resource Agency or its employees, agents, associates, officers, directors, or volunteers, will be the sole financial responsibility of the Community Resource Agency. The Community Resource Agency agrees to save and hold harmless and indemnify DentMed, Inc. and Releasees from all claims for loss or damage related to such misconduct.

This Agreement is governed by, and subject to, the laws of the State of Maryland. For purposes of litigating any dispute that arises directly or indirectly from the relationship of the Community Resource Agency and Releasees evidenced by this Agreement, the Community Resource Agency agrees that any such litigation shall be conducted only in the courts of Prince Frederick County, Maryland, or the federal courts serving Southern Maryland, and no other courts.

In compliance with the HIPAA Privacy Act: I agree to hold in confidence all personal and protected health information I may see, read, overhear, have access to, or come in contact with during and following the DentMed, Inc Pop-up Clinic.