Older Adult Dental Application

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Application Type

What type of application are you submitting?

Personal Information

First Name

M.I.

Last Name

Date of Birth

Gender Identity

Gender

Race

Ethnicity

Contact Information

Street Address

Apt./Unit

City

State

Zip Code

Mobile Phone

Home Phone

Email address

Preferred Communication

Responsible Party

Identify the Responsible Party

If "Other", List Here

Responsible Party Physical Address

Apt./Unit

City

State

Zip Code

Responsible Party Email Address

Medical Information

Physician's Name

Date of Last Exam

Pharmacy

Pharmacy Phone

Referral Source

Preferred Clinic Location

Financial Information

Do you have Medicaid Benefits?

Do you have Dental Insurance?

Do you have Medicare Benefits?

Medicare ID:

Do you have a Medicare Advantage Plan?

Medicare Advantage Care Plan Name:

Medicare Advantage Care Plan Number:

How many people are living in your household?

What is your household's monthly income (all sources combined)?

$

Dental Needs

Please describe any other dental problems you are having:

When was your last Dental visit?

Have you been to the Emergency Department because of dental pain?

When did you go to the ED for dental pain?

Community Needs

We would like to connect you with other services, if you need them:

Do you have a safe place to live?

Do you have healthy food choices in your home?

Are you able to fill the prescriptions prescribed by your doctor?

Do you need transportation to medical appointments?

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Consent for Examination and Treatment

I authorize Access Dental Care, New Hanover County Health and Human Services and their designated personnel to provide routine preventative diagnostic services. This consists of exam, x-rays and cleaning every 6-12 months. If any additional treatment is recommended, I understand that I will be provided with a treatment plan, written information about the treatment and a consent form.

I Agree

Permission to Use and Disclose Patient Health Information

I hereby acknowledge I received a copy of, or opportunity to read, NHCHD Notice of Privacy Practice and understand I may contact the NHCHD Privacy Office with questions about the content of this notice.

I Agree

Authorization and Signature

I authorize New Hanover County Department of Health and Human Services to share information about my situation, as appropriate, and to verify any information I have provided in this application for the purpose of determining my eligibility for assistance.

I affirm the information given on this application is truthful.

Full Legal Name

Initials

Date of Form Submission

All information provided on this form will remain confidential and will be available only to those who need to confirm eligibility for assistance and to those who process the assistance to be provided.

This project is being supported, in whole or in part, by the American Rescue Plan Act of 2021, awarded to New Hanover County Department of Health and Human Services by the U.S. Department of the Treasury.