Donated Dental Services (DDS)

Donated Dental Services (DDS) is sponsored by Dental Lifeline Network. General dentists, specialists, and labs donate their time, skills, and funding to provide comprehensive dental treatment to eligible patients in Rhode Island on a non-emergency basis. Each practitioner in the network takes 1-2 patients a year as 'free care' cases.

Donated Dental Services Application | Dental Lifeline Network " * " indicates required fields 1 Information and Referral Agency 2 Medical and Dental information 3 Income, Financial Assistance, Expenses Please fill out this information to the best of your ability. If you are unable to answer a required question type NONE or 0 for your answer.

Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific Please fill in the zip code and make sure the city and state appear County of Residence Please provide the county, not country.

This field is hidden when viewing the form This field is hidden when viewing the form Non-Binary/Non-Conforming We do not share this information with any outside agency in connection with you and your personal information American Indian/Alaskan Native Native Hawaiian/Pacific Islander *If you selected "Yes", please send a copy of your DD-214 or other proof of military service to your respective coordinator.

Their contact information can be found after you submit this application. Documentation can be sent at a later time. Upload DD-214 Max.

file size: 50 MB. This field is hidden when viewing the form What branch of the military did you serve in? Army Navy Marine Corps Air Force Coast Guard Alternate Contact Person Name * Alternate Contact Person's Phone * Have you received services through the Donated Dental Services (DDS) program before?

* If yes, in which state?

* Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific How did you hear about the DDS program?

Are you referred by an agency or have a caseworker/social worker with an agency, non-profit or hospital?

* Caseworker's Phone Number Caseworker e-mail address * This field is hidden when viewing the form Agency or Caseworker Address Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific Please fill out this information to the best of your ability.

If you are unable to answer a required question type NONE or 0 for your answer. Primary Physician's Name * Primary Physician's Phone Number * Has your doctor mentioned that you must have medically-necessary dental care? (examples: In order to start a medication, receive a transplant, receive head/neck radiation, etc.) * What is the reason your doctor provided?

* Please have our medical triage form completed by your medical doctor. If you do not have access to save this document now, a copy can be sent to you once your application is processed. You can upload it here if it is ready, or you can submit it at a later time.

This field is hidden when viewing the form Please check all that apply. If you check any of these, please have our triage form completed by your medical doctor: Please check all that apply.

If you check any of these, please have our triage form completed by your medical doctor: I have a artificial heart valve and/or stent I receive treatment for heart problems I am currently on dialysis I have had an organ transplant I am currently being treated for cancer I have rheumatoid arthritis I have Multiple Sclerosis I have an artificial joint or other orthopedic hardware This field is hidden when viewing the form Have you taken any of the following medications?

If you do not have access to save this document now, a copy will be sent to you once you are added to the waitlist. Max. file size: 50 MB, Max.

files: 5. Major Disabilities or Health Problems * Please include any health conditions you currently see a doctor or take medications to treat. Be as specific as possible.

This field is hidden when viewing the form Do you require wheelchair/ramp access? Please fill out this information to the best of your ability. If you are unable to answer a required question type NONE or 0 for your answer.

Briefly describe your dental problems: How many natural upper teeth do you have remaining? Please enter a number greater than or equal to 0 . How many natural lower teeth do you have remaining?

Please enter a number greater than or equal to 0 . This field is hidden when viewing the form Approximate Date of Last Dental Visit Approximate Date of Last Dental Visit Last Dentist's Phone Number How will you get to dental appointments?

* Please explain how will you get to dental appointments: Please list other cities or how far you are willing to travel in order to get dental treatment: Previous Next Save and Continue Later Household Financial Information Please fill out to the best of your ability. If you do not know an exact amount, enter your best estimate. If you are unable to answer a required question type NONE or 0 for your answer.

Does anyone live with you? * List the people (including minors) that live with you (Name, Age, Relationship to You, and Monthly Income of Each Person in the Household): Name Press the "+" sign to add a new person This field is hidden when viewing the form Total monthly income of other household members, not including you: Please enter a number greater than or equal to 0 .

If no, please explain why: * If you are employed, place of employment: * Your Monthly Employment Income: * Please enter a number greater than or equal to 0 . Is your spouse/significant other employed? * I don't have a spouse/significant other If no, please explain why: * If they are employed, place of employment: Spouse/Significant Other's Monthly Employment Income: * Please enter a number greater than or equal to 0 .

Child Support: Please enter a number greater than or equal to 0 . Please fill out to the best of your ability. If you are unable to answer a required question please type 0 for your answer.

Please mark any financial assistance that you (the applicant) receive: * Social Security (Retirement) Unemployement/Workers Compensation Temporary Assistance to Needy Families (TANF) *If you checked 'SSI or SSDI payment', please upload below or send a copy of your award letter or proof of disability to your respective coordinator.

Your Coordinator’s contact information can be found by going to the “State Programs” tab and clicking on your state of residence. Applicant's SSI or SSDI Payments * Max. file size: 50 MB, Max.

files: 5. Monthly Social Security (Retirement) Amount * Unemployment/Workers Compensation * Temporary Assistance to Needy Families (TANF) * Other Public Assistance: * Please provide any other public assistance not listed and the monthly amount you receive. This field is hidden when viewing the form If you chose NONE, please explain: Total Monthly Household Income * If you are not receiving disability, have you ever applied?

* Please mark each that applies to you: * Supplemental Nutrition Assistance Program (SNAP) benefits Type of Investments/Assets * Total Value of Investments/Assets * Monthly Amount of SNAP benefits * If you chose NONE, please explain: Do you receive Medicaid benefits? * Do you receive Medicare benefits? * This field is hidden when viewing the form Do you have a Medicare Advantage Plan?

Do you have Dental Insurance? This includes dental benefits through Medicaid/Medicare. * *If you selected "Yes", please send a copy of your dental benefits to your respective coordinator.

Their contact information can be found after you submit this application. Monthly Household Expenses Please fill out to the best of your ability. If you do not know an exact amount, enter your best estimate.

If you are unable to answer a required question, type NONE or 0 for your answer. Please provide your MONTHLY expenses in the following categories: How much is your monthly mortgage payment? * Please enter a number greater than or equal to 0 .

How much is your monthly rent? * Please enter a number greater than or equal to 0 . Credit Card/Loan Payments * Medications/Medical Cost * Out of Pocket Health Insurance * Do you have any cars in your household?

* Please provide the make, model and year of each car. * Make Press the "+" sign to add a new car Car Payment Total * Please enter a number greater than or equal to 0 . Car Insurance/Car Expense/Gas Total * Total Monthly Household Expenses * Are any family members able to contribute to costs of your dental treatment?

* If yes, please explain: * Are any other sources available to help pay for dental care? * (i.e. churches, service organizations, other agencies, etc?) If yes, please explain: * Additional Information Use this area to add any other information you would like to share with us.

Previous Next Save and Continue Later Agreement - Release of Information * I understand that I will need to provide personal information that includes but, is not limited to medical, dental, and financial condition.

I authorize Dental Lifeline Network (DLN) to obtain information from, and share information with my physician(s), dentist(s), contact people I listed, and/or government or private agencies in order to determine my eligibility for programs at DLN. I understand information provided by me or others as noted above may be given only to the volunteers involved in my treatment and will be held confidential.

I authorize DLN to share information with and obtain information about me with one or more DLN dentist(s) volunteering through the program. I understand if my disability is AIDS or HIV related, I authorize DLN to release information about my AIDS or HIV-related medical condition to one or more DLN volunteer dentists in the program and hold DLN harmless for doing so.

I also understand that I have a right to revoke this consent at any time except to the extent that the person who is to make the disclosure has already acted in reliance on it. Furthermore, this consent will expire at either the termination or completion of my treatment through programs at DLN. 2.

Eligibility and Treatment Understanding 2. Eligibility and Treatment Understanding * I realize that my application to DLN does not assure I will be referred for an examination or that I will be accepted as a patient following an examination. I understand that DLN will determine whether I am eligible for the program and, if so, will try to refer me to a participating volunteer dentist.

I further understand that the dentist, not the organization, is solely responsible for diagnosis and any possible treatment that I may receive for my dental needs. I understand that the dentist(s) has volunteered to treat my existing dental condition only and is not obligated to provide donated care in the future or to maintain me as a patient.

I understand that DLN volunteer dentists may discontinue providing services to me at any time. I understand that I am responsible for obtaining the services of an alternate dentist. I also understand that DLN has no responsibility to assist me in obtaining the services of an alternate dentist.

I agree to find and obtain reliable transportation to and from all dental appointments. Also, I agree to arrive on time to all of my appointments and will make every effort to arrive 15 minutes early prior to the time of my appointment. I agree to keep all appointments unless I have a serious emergency and rescheduling is unavoidable.

If I have an emergency and I am unable to keep an appointment, I will follow the dentist's policy regarding cancellation and call the dentist's office to cancel my appointment at least 24-48 hours in advance. I understand that if I miss an appointment without calling in advance or reschedule or cancel more than one appointment, I may be terminated from the DDS program.

I shall not ask the DDS volunteer dentist for pain medication and understand that medications will only be supplied or prescribed to me by the dentist when it is absolutely necessary and at their discretion and at the dentist’s discretion.

To the best of my knowledge, the information provided in this application is a full and accurate disclosure of my current physical, medical, and financial status and I agree to the terms and conditions stated above. To certify your application, please provide an electronic signature (type your full name). * 4.

Optional Photo and Information Consent Form 4. Photo and Information Consent Form Please provide an electronic signature (type your full name) to authorize use of your photo or information as described. * Previous Submit Save and Continue Later