DRAFT Kent County School Based DENTAL Student Enrollment Form (English)

School Based Dental Centers

Student Enrollment Information | Kent County Public Schools
Please review the following information before beginning the enrollment form.

School Based Dental Centers are a partnership between Choptank Community Health and Kent County Public Schools. This program allows students to receive dental care right at school. Care is coordinated with your student's primary primary dentist. Choptank Health will always obtain parent/guardian permission before seeing or treating your student.

Services available in the School Based Dental Centers include:
- Dental screening
- Polishing / cleaning
- Fluoride (may be applied twice)
- Dental sealants
- Oral health education
- Dental emergency referrals
The School Based Dental Program does not take the place of your primary Dentist. A Dental Hygienist will screen your child to determine which services will be provided or if a referral is necessary. The Hygienist pro-vides care in the school setting that promotes healthy teeth and gums. Your child should go to your dental office for a complete exam with x-rays as often as recommended by your Dentist.

To complete this enrollment form, you will need:
- Your student's health history, including medications, allergies, and recent surgeries
- Your family health history
- Dental insurance information, if applicable. NOTE: If your student does not have insurance, they are still eligible to receive services. You may apply for the Sliding Fee program, which provides discounted services based on household income.
If you have questions about the program, please contact Choptank Community Health System at 410-479-4306 Ext. 1038.

School Based Dental Centers

Student Enrollment Form | Kent County Public Schools
My child is a student at:*
My child's grade is:*
My child's homeroom teacher is:

Student Information
Student's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:*

MonthDayYear
Gender*

MaleFemalePrefer not to respond
Social Security Number:
Race:*
Hispanic / Latino?*

YesNo
Preferred Language:*
Primary Care Doctor
Name of Doctor:
Doctor's Phone Number:
Please enter a valid phone number.
Primary Dentist
Name of Dentist:
Dentist's Phone Number:
Please enter a valid phone number.
Pharmacy
Name of Pharmacy:
Pharmacy's Phone Number:
Please enter a valid phone number.

Parent / Guardian Information
Parent / Guardian Name*

First NameLast Name
Relationship to Student:*
Preferred Language:*
Phone Number #1*
Please enter a valid phone number.
Phone Number #2 (optional)
Please enter a valid phone number.
Is it okay to text you?*

YesNo
Email
example@example.com
Emergency Contact Information
Name of Emergency Contact*

First NameLast Name
Relationship to Student:*
Phone Number #1*
Please enter a valid phone number.
Phone Number #2 (optional)
Please enter a valid phone number.

Dental Insurance Information
Does your child have dental insurance?*

YesNo
NOTE: If your student does not have dental insurance, they are still eligible to receive service. You may apply for the Sliding Fee program later in this form.

If you have dental insurance but do not have your insurance information available at this time, you may provide it at a later date.
Insurance Name:
Policy / Member ID Number:
Group Number:
Subscriber Name:

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Claims Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Sliding Fee Information

If you are not interested in applying for the Sliding Fee, please click "Next" at the bottom of the page. Patients on the sliding fee program can receive discounts that are billed based upon their income. All patients and their families are eligible to apply for the sliding fee program, even if they have insurance.
Would you like to apply for the Sliding Fee?

YesNo
If yes, number of people in your household:
If yes, annual household income (enter number only):

Consent & Signature

By signing below, you agree:
I understand that my signature gives consent for the CCHS School Based Dental Program Providers to treat my child and to communicate with my child’s primary health care provider. I give CCHS permission to call my home, leave a message on a machine or with a person regarding healthcare information. I understand that my child’s health information will be used for treatment, payment and health care operations. CCHS may also mail healthcare information to my home. I recognize that school directories may be used to obtain information left blank on the enrollment form. My child’s immunization record may be shared between the School Nurse and the School Based Dental Program. For the purposes of care coordination and case management School Clinical Staff will have access to the SBDP health records and School Clinical Staff shall share health information with the SBDP staff, and. School Clinical Staff are required to treat the information in the SBDP health record as confidential and comply with the HIPAA Privacy Rule. Under no circumstances, do SBDP records become part of the student’s school health record. I understand that services provided to my child will be billed to my insurance carrier or Medical Assistance. I may receive a bill from CCHS for copays and/or deductibles. I understand that my signature indicates that I have had the opportunity to receive and review the Choptank Community Health’s Notice of Privacy Practices. If I do not have insurance, I will be billed for the full cost of services or with a sliding fee discount if applicable.
Signature*

Clear
NOTE: If you need to enroll another student, click the "Submit" button below, then click the "Enroll Another Student" button on the next screen.
Should be Empty:

School Based Dental Centers

School Based Dental Centers

Student Information

Primary Care Doctor

Primary Dentist

Pharmacy

Parent / Guardian Information

Emergency Contact Information

Dental Insurance Information

Sliding Fee Information

Student's Health & Dental History

Family History

Consent & Signature