All Kids School-Based Dental Program Consent Form
This consent form allows parents or guardians to authorize dental services for their eligible children at school. It includes important health information and consent details. Ensure all information is completed accurately for the dental provider's review.
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How do I fill this out?
To fill out this form, start by providing your child's personal information in the required fields. Next, ensure that you indicate your consent by signing in the designated area. Finally, review all provided information for accuracy prior to submission.
How to fill out the All Kids School-Based Dental Program Consent Form?
1
Read the consent form carefully.
2
Fill in your child's personal and health information.
3
Indicate consent by signing the form.
4
Check your information for accuracy.
5
Submit the completed form by the due date.
Who needs the All Kids School-Based Dental Program Consent Form?
1
Parents or guardians of children eligible for dental services.
2
School administrators who need to ensure proper consent is obtained.
3
Dental providers offering services at schools.
4
Health care professionals involved in the child's care.
5
Qualified staff members coordinating health services in schools.
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What are the instructions for submitting this form?
Please submit the completed form to your child's school office by the indicated deadline. You can also fax the finished form to the dental coordinator at 309-382-6404 or email it to the school's health services department. Ensure you retain a copy of the submitted form for your records.
What are the important dates for this form in 2024 and 2025?
For the 2024 dental program, services are expected to begin in early spring. Forms should be submitted by your child's school deadline, which is usually a week prior to the scheduled dental visits. For 2025, keep an eye out for announcements in early winter regarding program details and submission timelines.
What is the purpose of this form?
The All Kids School-Based Dental Program Consent Form serves to authoritize dental services provided by Miles of Smiles, Ltd. for eligible students. This program aims to ensure that children receive essential dental care conveniently at their school. Completing this form is crucial for parents or guardians to grant consent and share pertinent health information with dental providers.
Tell me about this form and its components and fields line-by-line.
- 1. Child's Legal Name: The full name of the child requiring dental services.
- 2. Birth Date: The date of birth of the child.
- 3. Address: The home address of the child.
- 4. Gender: The gender of the child.
- 5. Does your child have a dentist?: A yes/no field to indicate if the child currently has a dentist.
- 6. Medicaid Enrollment: Information regarding the child’s enrollment in Medicaid or All Kids program.
- 7. Private Dental Insurance: Details regarding any private dental insurance the child may have.
- 8. Health History: A section to check relevant medical history and allergies.
What happens if I fail to submit this form?
Failure to submit this form can result in your child missing out on the dental services provided at school. Without proper consent and medical information, the dental provider cannot deliver the necessary treatments. It is crucial to ensure the form is completed and returned by the deadline to facilitate your child's care.
- Missing Dental Care: Without submission, children will not receive vital dental examinations.
- Increased Dental Problems: Skipping preventative care can lead to untreated dental issues.
- Potential Health Risks: Inadequate dental care can result in broader health concerns.
How do I know when to use this form?
- 1. New Enrollment: When a child first enrolls in the dental program.
- 2. Annual Consent: To provide consent for yearly dental services.
- 3. Updating Health Records: To update any medical history or changes in dental insurance.
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