Kinston Community Health Center School Based Oral Health Program Registration Packet (English)

The Kinston Community Health Center Junius Rose Dental Clinic, in partnership with Lenior County Public Schools, is pleased to announce that your child can receive the following dental services at school : •Dental Exam and Diagnosis •Dental Cleaning •Dental X-Rays •Dental Sealants •Fluoride Treatments •Oral Hygiene Instructions

DENTAL PROGRAM DETAILS

•Services are provided by licensed dentists, licensed hygienists and certified dental assistants. In some cases, dental students may accompany the dental professionals to provide educational and preventive services.

•Students will receive oral health screenings, complete dental exams, cleanings, fluoride treatment, and oral hygiene instructions by the dental provider. Students will also receive x-rays as needed. Dental sealants will be placed as indicated. Following the visit, students will receive a dental report card which will be sent home. This report card will explain the treatment completed. In addition, it will explain if your student needs to be seen for further treatment. After the dental visit, a member of our dental team will be in contact to schedule an appointment at our main dental clinic.

•Some patients may need to be seen for specialty services and will be referred to a dental provider in your community. Referrals are dependent upon the extent of the student’s dental needs as well as the behavior.

•Informed consent indicates your awareness of sufficient information to allow you to make an informed personal choice concerning the patient’s dental treatment. Most patients do not encounter any difficulties with their treatment. If the patient indicates any resistance to the dental procedure, we will discontinue the treatment.

•The Tell-Show-Do technique is often used to gain the cooperation and confidence of the dental patient. The dental provider explains what they are going to do and then shows what they are going to do. The provider makes every effort to be a partner in care with the patient and family, making the dental visit pleasant and informative.

•This dental program is available to all students who DO NOT have a regular dentist. If your student has a dentist, please be sure they continue to see their dentist regularly

DENTAL COVERAGE INFORMATION

Services provided by the mobile dental program will affect coverage for other dental visits. If you have dental insurance or Medicaid, dental services will be billed directly. If your child does not have dental insurance, it is the parent’s responsibility to speak to a representative of Kinston Community Health Center to apply for the Slide Fee Discount Program.

CONSENT TO PARTICIPATE

IF YOU AGREE TO HAVE YOUR STUDENT PARTICIPATE , PLEASE CLICK "YES" AND ENTER ALL REQUESTED INFORMATION TO REGISTER YOUR STUDENT FOR THE DENTAL PROGRAM BELOW.

Please note: If your child already has a dentist and you DO NOT want to transfer to this mobile clinic, please DO NOT proceed with this form. Please be sure your child continues to see their dentist regularly. Thank you.
Please read and if you agree, click "YES" before proceeding.*

YES. I have read and understand the mobile dental program. I give permission for my child to participate in the mobile dental program.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Teacher*
School:*
Student Grade*
Relationship to Student:*

ParentGuardian *Please note: Documentation of legal guardianship status will need to be submitted to our office before the student is seen.
Parent/Legal Guardian Name:*

First NameLast Name
Parent/Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date

Dental Insurance Information

Please complete the following information regarding your child's current dental insurance
Does your child have dental coverage?*

YESNO
Please check which dental coverage your child has:*

MedicaidNC HealthchoiceDental Insurance Plan
Since your child does not have dental coverage, are you interested in applying for the Slide Fee Discount Program

YESNO
Medicaid Policy Number:*
Health Choice Policy Number:*
Dental Insurance Plan Name: Dental Insurance Plan Name*
Plan Subscriber Name:  Subscriber Name*
Plan Subscriber Date of Birth: Subscriber Date of Birth*
Dental Policy Number:   Dental Policy Number*
Please sign below for consent to contact you regarding applying for the Slide Fee Discount Program

Clear
Consent

Please read the following and sign to give consent for your child to be seen for dental treatment.
•I understand that this consent will stay in effect for the current school year. I agree that the above information is accurate and complete to the best of my knowledge. I will not hold the school, the provider, staff or Kinston Community Health Center responsible for any errors or omissions I may have made in the completion of this form. I agree that it is my responsibility as the parent/guardian’s responsibility to notify the provider, staff and/or the school nurse of any changes in my child’s health information.

•I understand that a copy of my child’s dental treatment and exam findings will be given to the school nurse or designated oral health person and that all information will be kept confidential.

•I authorize Kinston Community Health Center to file the patient’s insurance and for the plan to pay for any services provided.

• I have been provided a copy of the Notice of Privacy Practices(available to print at the end of the registration).

•I understand this program may only use my child’s health information for treatment, payment, health care operations, and program evaluation.

•I give consent for my student to have preventive services completed at the school oral health program including exam, cleaning, fluoride, x-rays, and dental sealants placed, if indicated. I understand that I will be notified of the findings from the dental exam. If further dental treatment is needed, my child will need to be seen as a patient at the Kinston Community Health Center main dental clinic.

•I have read and completely understand the dental program and I give permission to have my child participate.
Signature

Clear

Should be Empty:

	YES	NO
AIDS/HIV
Artificial Joints
Asthma
Cancer
Diabetes
Heart Conditions
Heart Murmur
Hepatitis
High Blood Pressure
Kidney Problems
Mitral Valve Prolapse
Rheumatic Fever
Sickle Cell Disease
Tuberculosis (TB)
Other (type details below)

	YES	NO
AIDS/HIV
Artificial Heart Valves
Artificial Joints
Asthma
Cancer
Diabetes
Heart Conditions
Heart Murmur
Hepatitis
High Blood Pressure
Kidney Problems
Mitral Valve Prolapse
Rheumatic Fever
Sickle Cell Disease (not trait)
Tuberculosis (TB)
Other (please type details below)

Kinston Community Health Center School Based Oral Health Program Registration Form

Patient Medical Information

Dental Insurance Information

Consent

KINSTON COMMUNITY HEALTH CENTER, INC. PATIENT DEMOGRAPHIC FORM

HIPAA – AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO INDIVIDUALS FAMILY MEMBERS

Contact Methods

Acknowledgment of Receipt of Notice of Privacy Practices, Patient Rights & Responsibilities, and Patient Bill of Rights