New Patient Application

We are pleased to provide the following information about the Donated Dental Services Program and application procedures.

ELIGIBILITY: Dentists throughout the state have volunteered to provide comprehensive dental care at no charge to people of all ages, who, because of a serious disability of impaired mental and/or physical health, lack adequate income to pay for needed dental care. Dental services are provided free of charge to eligible individuals. All patients admitted into the program must have transportation to the dental office and must keep all appointments. The Donated Dental Services Program is unable to provide sedation services for simple procedures, such as x-rays and cleanings.


Step 1: Please print, complete, sign, and return the application.
Please include a copy of your SSI/SSDI award letter with this application.
Step 2: When your application has come up for review, a patient care coordinator will call to obtain additional information. Please do not call to check on the status of your application. These phone calls take up much of our time and only delay treatment time for all of our clients. A coordinator will call you when you when your application is up for review.
Step 3: The patient-care coordinator will send a referral letter with the patient’s information to a volunteer dentist.
Step 4: You will be contacted by a dentist’s office to schedule an appointment. It is very important that you do not miss any appointments or arrive late. Failure to keep appointments and be on time will result in termination from program.

Please be patient. The patient care coordinator will contact you when your application has come up for review.

 Please include a copy of your SSI/SSDI award letter with this application.

Application 2017 (LINK TO PDF)