New Patient Application HELP Dental Clinic

Who is this form for? 

This form is for adults (18+) who are currently not covered by dental insurance or whose dental supplement does not cover the work they need done. 
HELP can accept applications from individuals with: 

No Dental Insurance
(you can still have health insurance)
Medicare (w/ no dental supplement)
Medicare w/ dental supplement (in some cases)
Veterans receiving medical care from the Hampton VA Medical Center

If you are currently receiving Medicaid, you will need to call the number on the back of your card to find out which dentists in our area will accept your coverage. HELP does not currently accept Medicaid. 

Not sure whether or not you may qualify? Please give us a call and we can help you determine if you'll need to fill out this application.
757-586-5107

Patient information

You as a patient consent to such medical/dental treatment and examinations, including diagnostic and lab procedures, dental procedures including extractions that are necessary treatment in the opinion of my provider (e.g., physician, nurse practitioner, dentist).

Immunity from civil liability for any act or omission resulting in death or injury to a patient if: The volunteer was acting in good faith and in the course and scope of the volunteer’s duties or functions within the organization.  The services provided are within the scope of the license of the volunteer or employee.

I understand that should a HELP employee or volunteer be exposed to my blood/body fluid in a way that might allow transmission of infection due to blood borne diseases (HIV, Hep A,B,C) or other communicable diseases, according to Virginia State Law, for the safety, health and possible treatment of the health care provider/staff member, samples of my blood or bodily fluid may be tested for infection at NO COST to me.  I also understand that health care providers are obligated to submit to blood tests for certain infectious diseases if I am inadvertently exposed to their blood or body fluid during my treatment.

Extraction of teeth is an irreversible process and, whether routine or difficult, is a surgical procedure.  As in any surgery, there are some risks.  They include, but are not limited to, the following:

1.  Swelling and/or bruising and discomfort in the surgery area.

2.  Stretching of the corners of the mouth resulting in cracking or bruising.

3.  Possible infection requiring additional treatment.

4.  Dry Socket- Jaw pain beginning a few days after surgery usually requiring additional care.   It is more common from lower extractions, especially wisdom teeth.

5.  Possible damage to adjacent teeth, especially those with large fillings or crowns (caps).

6.  Numbness, pain, or altered sensations in the teeth, gums, lip, tongue (including possible loss of taste sensation) and chin, due to the closeness of tooth roots (especially wisdom teeth) to the nerves which can be bruised or damaged.  Almost always sensation returns to normal, but in rare cases, the loss may be permanent.

7.  Trismus- Limited jaw opening due to inflammation or swelling, most common after wisdom tooth removal.  Sometimes it is a result of Jaw Joint Disorder (TMJ), especially when TMJ disease already exists.

8.  Bleeding- Significant bleeding is not common, but persistent oozing can be expected for several hours.

9.  Sharp ridges or bone splinters may form later at the edge of the socket.  These usually require another surgery to smooth or remove.

10.  Incomplete removal of tooth fragments.  To avoid injury to vital structures such as nerves or sinus, sometimes small root tips may be left in place.

11.  Sinus Involvement.  The roots of the upper back teeth are often close to the sinus and sometimes a piece of root can be displaced into the sinus or an opening may occur into the mouth that may require additional care.

12.  Jaw Fracture- While quite rare, it is possible in difficult or deeply impacted teeth.

Your personal information:

The information collected on this application form will be used by the HELP Dental Clinic (hereafter the ‘Practice’) for the purposes of healthcare related services and practice administration in accordance with HIPPA.
Personal data relating to you will be retained by the Practice for the purposes of providing you with medical/dental and healthcare related services both in the Practice and where appropriate at the premises of other healthcare providers. This may require your personal data including relevant details of your medical history to be shared with other healthcare providers for the purpose of referrals and for other lawful purposes related to the Practice procedures. 

HELP Dental Clinic takes confidentiality and the protection of your personal data very seriously and we will never share your information with any third parties, companies or otherwise without your explicit consent prior to doing this.

You have the right to:

Have your health record sent directly to another provider
Have your health record sent directly to Social Security Disability by request
Ask us to limit the information we share
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information

We may use and share your information as we:

Help manage the health care treatment you receive
Report statistical information on behalf of our organization
Help with public health and safety issues
We will share information about you if state or federal laws require the information be shared
We can share health information with a coroner, medical examiner, or funeral director when an individual die.
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
I understand that the Practice has the right to accept or decline my registration application at any time.

I agree to abide by the following responsibilities and conditions:

PATIENT RESPONSIBILITY

Clinic:

• I will update any changes in household income, address, phone number, or other personal information in a timely manner.
• I understand my responsibility to remain in good standing by applying every 12 months with current documents.  If my coverage lapses, I understand that medications and treatment will not take place until I re-enroll.
• Be respectful to staff/providers/specialists/volunteers. HELP will not tolerate disrespectful or rude behaviour toward any staff or volunteer, including specialists and their staff to which patients may be referred. 
• Appointments must be cancelled 48 hours prior to the scheduled appointment. Not enough notice or no shows will result in a $25.00 fine. 
• If I am suspected to be under the influence of alcohol or drugs, I will be asked to reschedule my appointment.
• I will be required to refrain from the use of electronics(cell phones, etc.) while receiving treatment. 

HELP is a part of the Virginia Association of Free & Charitable Clinics which requires our clinic to gather specific information your current status of healthcare coverage, household makeup, and household income. This information also helps clinic staff determine the cost of treatments with sliding scale pricing based on household income. 

To accomplish that, we will need the following documents: 

• Identification (government-issued ID)
  Don't have it? Don't sweat it! Give us what you have. 
  
  
• Address Verification (first page of a lease agreement, utility bill for your current residence, a letter from a government agency)
  
  
• Household Income Verification (recent W-2s, first page of your taxes, last 4 pay stubs, benefits award letter) 
  We need to know the household's income, so please include any information from the earners within your household. 
  
  
• The Total Number of People in your household (for example, 2 adults + 2 children = 4 total)

If you selected an answer of more than 1 for Household Members Earning Income and you file your taxes jointly, please include the other household member's income verification documents in your application. If you filed taxes jointly, you may also submit a copy of the front page of your most recent tax return. 

BY SIGNING BELOW, I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION TO THE BEST OF MY KNOWLEDGE. THE ABOVE QUESTIONS HAVE BEEN ACCURATELY ANSWERED.
I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BY DANGEROUS TO MY HEALTH.

Help us better understand the process!