Appalachian District Health Department

 www.AppHealthCare.com 

Caring for our Community


Dear Parent/Guardian, 

AppHealthCare is working with the school system to provide dental health services to students who do not currently have a dentist. Dental health care is an important part of overall health and we are determined to help your child have a healthy smile for life. AppHealthCare is a local health department and federally qualified health center (FQHC) that provides dental services on-site at schools using portable equipment and health department staff. We encourage your child to receive dental care, and we would appreciate the opportunity to care for your child. 

As a local health department and FQHC, we are required to collect information on the patients we serve. This information helps us to serve our patients better. This information will be kept confidential and will not be shared or sold. If you are interested in your child receiving dental services, we would appreciate your attention to the forms included with this letter and complete them in their entirety so we can best serve your child. These forms will be kept current and on file for the FY 22-23 school year. 

If you have any questions, please reach out to us. 

Thank you, 

AppHealthCare Dental Health Services Team 

Phone: (336) 246-9449 ext: 2131 

www.AppHealthCare.com 




_________________________________________________________________________________________________________________

Business Office                     Alleghany Co. Health Center         Ashe Co. Health Center      Watauga Co. Health Center

157 Health Services Rd        157 Health Services Rd                413 McConnell Street          126 Poplar Grove Connector

PO Box 309                             PO BOX 309                                PO BOX 208                        PO BOX 307

Sparta, NC 28675                   Sparta, NC 28675                        Jefferson, NC 28640            Boone, NC 28607

336-372-5641                         336-372-5641                               336-246-9449                       828-264-4995

336-372-7793 Fax                 336-372-7793 Fax                        336-246-8163 Fax              828-264-4997 Fax



Dental Consent Form

AppHealthCare is pleased to be able to provide preventive care at your child’s school. Thank you for your interest in our Portable Dental Program. Our program provides the following services for students via licensed dental professionals during school hours:

Comprehensive Exams

Limited Exams

Tele-Dentistry Exams

Dental Cleanings

Dental Sealants

Fluoride Application

Dental Screenings

Oral Hygiene Instruction

Nutritional Counseling

Radiographs (X-Rays)

Please note this dental program is available for all children who do NOT have a regular dentist.

Student Name (First, Middle and Last)*
Preferred Name

I voluntarily consent to routine dental treatment by AppHealthCare for the above named minor for whom I am parent or guardian. I understand that specific and separate consents will be requested from me prior to any non-routine, hazardous, or major treatment. I request payment of authorized Medicare, Medicaid, and other third party payers’ benefits on my behalf for any services furnished me by this agency. I authorize AppHealthCare to release information needed to determine benefits for this service. I understand I will be responsible for charges not covered by my insurance, as applicable. I understand that I may pay my charges using check, cash, credit card, or debit card. I authorize the release of information to the extent necessary to carry out the following purposes: fiscal and accounting, or consultation and referral. I certify the financial information I have given is correct and give my permission for AppHealthCare to contact my employer or any other agency for verification, if necessary. I understand I should notify AppHealthCare if my income or other information changes. I also understand that payment plans are available for any balance due and that I may choose to have a payment plan by contacting AppHealthCare if I am unable to pay the full balance due. AppHealthCare participates in the NC Debt Set-off Program as authorized by the Set-off Debt Collection Act (N.C.G.S. 150A 18C-134). Any unpaid account balance of $50.00 or more that is more than 90 days past due may be withheld from your income tax refund or lottery winnings. Patients who have verified their income as part of the Sliding Fee Scale discount program and are determined to be at or below 100% of the Federal Poverty Level will not be subject to these collections. By signing above, I hereby acknowledge that I have access to a copy of the “Notice of Privacy Practices” (upon request) for AppHealthCare and understand that I may contact the HIPAA Privacy Officer if I have questions about the content of the notice.

Acknowledgment of services that will be provided*
If you do not wish for your student to participate in the school dental program, please DO NOT complete this form.
Use your mouse or finger to draw your signature above
Date

Patient Registration

Date of Birth*
Address*
Parent/Guardian Name*

Health Care Provider Information

This information is used to send visit information to your primary care provider

If none, would you like AppHealthCare to be your child's doctor?*
If none, would you like AppHealthCare to be your child's dentist?*

Health History

Patient Health History: Please check any conditions or health concerns your child has or has had in the past:*
Does your child have allergies to any of the following?
Emergency Contact Name
Use your mouse or finger to draw your signature above
Date

Dental Insurance

Skip this section if no dental insurance

Insurance Info (Check ALL that apply):
Group (Policy and Group # not required if copy of card is uploaded)
No File Chosen
File uploads may not work on some mobile devices.
Policy Holder's Name/ relationship
Policy Holder's Date of Birth
Insurance Card
No File Chosen
File uploads may not work on some mobile devices.

Income Information

If you prefer not to provide this information.  Check question below and skip to next section

We understand that some insured patients may prefer to not disclose individual income data. By not disclosing family income, however, you are acknowledging that you understand that we will not be able to provide the Sliding Fee Scale discounts that you may be eligible for, which may offer significant savings.

Indicate by checking the box if you still:

Please Complete Household Information below as you may be eligible for a Sliding Fee Scale Discount. Proof of income must be provided within 10 days of date of service to avoid fees being charged at full price and patient receiving a bill. AppHealthCare sliding fee discounts will not apply to outside services, if you are referred to another provider or agency for additional care.

Household Member # 1 Name
Employed
Household Member # 2 Name
Employed
Household Member # 3 Name
Employed
Household Member # 4 Name
Employed

Payment Information

Please note: AppHealthCare participates in the NC Debt Set-off program as a means to collect unpaid charges. If you accrue unpaid debts they may be deducted from your NC State Tax Refund. If patient is a child please complete for parent/caregiver information below:

Father's Name
Mother's Name
Use your mouse or finger to draw your signature above
Date
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