1- Do you meet the patient requirements?

To be a HealthLink Patient:

• You must be at least 18 years old
• You must live in either Bucks County or Montgomery County
• You must not have dental insurance
• You or your spouse/domestic partner must be employed (full-time,part-time, or seasonally) and
• The total income of your household must be less than the limits listed below (See Chart)       

If you do not meet HealthLink's requirements, there are other resources that are available to you.  CLICK HERE to view other places to receive free or low-cost dental care.

2- Complete the online application AND send us these documents.

• Most recent 2 months of paystubs;
• Completed federal tax return (Form 1040) & schedules, if applicable, for the current year;
• Proof of residency, such as utility bill or signed rental leease; and
• Photo ID (drivers license, passport, or work ID)

GENERAL INFORMATION

HealthLink ONLY serves residents from Bucks County or Montgomery County (Pennsylvania). Do not complete this application if you do not reside in either of these two counties.

DENTAL INSURANCE INFORMATION

If you have dental insurance, you do not qualify to be a HealthLink patient. Do not complete this application.

EMPLOYMENT INFORMATION

You MUST provide us with either:

• YOUR employment information - OR -
• Employment information for your SPOUSE or domestic partner

If you are not working and you do not have a spouse/domestic partner who is working, you do not qualify to be a patient.

Do not continue this application. Instead, click here to view other resources for dental care that may be available to you.

 

VETERANS: Please call us at (215) 364-4247 to discuss your application.

FINANCIAL INFORMATION

FAMILY INFORMATION

Sex/Ethnic Origin Statement- Completing this section of the form is OPTIONAL. HealthLink welcomes patients of all backgrounds. This information will be used for statistical purposes only.

Certification

I certify that the information on this application and the financial Information provided is correct. I give permission to verify income from any or all of the sources provided. I understand that any false statement with regard to my finances, dependents, address, place of employment, insurances and who resides in my household will be cause for denial of services and dismissal from HealthLink services permanently. I understand that if I meet Healthlink's initial eligibility criteria I will be contacted to schedule an eligibility confirmation appointment. At the confirmation appointment, which I must be present for, I will recive final determination of my acceptance as a HealthLink patient. I know that a dental appointment can only be made at the completion of a satisfactory confirmation appointment.

Medication List Key:

#=Amt of tabs   RX=Prescribed Med    D/C=Discontinued Meds (Updated &Inital)

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that may be taking, could have an important interrelationship with the dentistry that you will be receiving. Thank you for answering the following questions.

To Become A Patient at HealthLink, You Must Still Provide Us With These Documents:

• Most recent 2 months of paystubs;
• Completed federal tax return (Form 1040) & schedules, if applicable, for the current year;
• Proof of residency, such as utility bill or signed rental lease; and
• Photo ID (drivers license, passport, or work ID)

 

You can fax copies of the documents to us at (215) 791-1907, email them to jsantiago@healthlinkdental.org, or mail them to us at:

HealthLink Dental Clinic

Attn: Patient Application

444 N. York Road

Hatboro, PA 19040

You will not be accepted as a patient and will not be able to schedule your first appointment until we have all of these documents.