Wyoming Department of Health

Community and Public Health Division

Dental Health

Application for the Marginal Dental Program

APPLICATION FOR THE MARGINAL DENTAL PROGRAM
6101 Yellowstone Road, Suite 420, Cheyenne, WY 82002

Patient Information:

Name:

Male / Female

Birth Date:

Mailing Address:

Street Address

City

County

Zip Code

Physical Address

Street Address

City

County

Zip Code

Social Security Number: (Optional)

Home Phone:

Work Phone:

Message Phone:

Parent/Guardian Information:

Name of Father / (Step) / Guardian:

Name of Mother / (Step) / Guardian:

Address if different from Patient:

Total Number of People Living In Household:______________(Complete Family Case Sheet)

Dentist/PHN:

Name and Address of Dentist:

Name/County of Public Health Nurse / School Nurse

DENTAL INSURANCE & BENEFITS: (Attach coverage information)

Insured's Name, Company Name, Address

Benefits

	Dental Insurance Benefits must be applied to cost of care before Dental Health can make payment.
	You must complete all three pages before mailing application to Dental Health Program, 6101 Yellowstone Road, Suite 420, Cheyenne, WY 82002. Please sign and date page number 3.

CONFIDENTIAL FINANCIAL INFORMATION

APPLICATION WILL BE CONSIDERED INCOMPLETE WITHOUT RECENT PAY STUBS AND/OR LAST YEARS TAX RETURN

PERSONAL INCOME (INCLUDE ALL INCOME FROM ALL MEMBERS IN THE HOUSEHOLD)

(MEMBER-Parent (s), stepparent, legal guardian, parent significant other, grandparent, sibling, aunt/uncle,etc)

Member Relationship:
Occupation
Current Employer
How many months of the year are you employed?
Months/Years at Current Job
Monthly Gross Income
Amount in Savings
Child Support, Alimony, or Family Benefits Received
Social Security – SSI, SSDI, Retirement or Survivors Benefits
Other Income: Dividends/Interest, Business Income, (i.e Rental)Real Estate
Unemployment/Workers' Compensation
Other, Farm
Per Capita

MONTHLY EXPENSES

Medical	Balance	Payment	HouseHold	Amount
Doctor	$	$	Housing payments
Dentist	$	$
Hospital/Lab	$	$	Child Support Paid
Pharmacy	$	$

FAMILY CASE SHEET

This social summary will be used in helping to determine eligibility for Dental Services provided by the Dental Health Program. All information given is kept confidential.

Patient’s Name:		DOB:
Address
City	State	Zip

ALL MEMBERS IN HOUSEHOLD & NOT INCLUDING PATIENT

Last Name, first Name

Relationship to Patient

Birth date (mm/dd/yy)

Occupation or School

I (We) apply for care of _____________________________________by Dental Health Services. I will apply all dental insurance benefits I receive to the cost of my child’s care. I understand that Dental Health Services/Marginal Program must give prior authorization for any care for which the program is to pay.

The information you have provided will remain confidential with the Department of Health – Dental Health Services, EXCEPT in the following circumstances:

The Dental Health Program (DHP) as part of the Department of Health is a covered entity. DHP may request from any state agency, insurer, group health plan, health maintenance organization or similar entity any or all of your protected health information. This information may be used or disclosed for the process of treatment, payment or healthcare operations. This is in accordance with the Health Information Portability and Accountability Act section 164.502(a)(1)(ii). Please see your Client Privacy Rights Policy for use and disclosure of your protected health information.

I hereby authorize the release of information limited to payment information (as described above) to state agencies, insurers, group dental plans, third party administrators, health maintenance organizations or similar entities for the purpose set forth above.

ALL INFORMATION I HAVE PROVIDED ON THIS APPLICATION (3 pages) IS TRUE TO THE BEST OF MY KNOWLEDGE.

Signature:

Date: