New Patient Application

To be eligible you must: 

• Apply and be accepted into the program. 
• You must be a Maryland adult (18+years) with an intellectual, physical, and/or developmental disabilities and be unable to pay for your dental care.  
• Those with private dental insurance are not eligible for this program.  
• All dental treatment and labs are provided at no cost to you in a private dental office.  
• All patients admitted into the program must have transportation to the dental office and must keep all appointments.  
• We are not emergency services.
• If you are accepted into the program, services are once in a lifetime, so after completion of treatment, you cannot apply again. 

Please note: Our program is unable to provide sedation services.

If you have private dental insurance you are not eligible for this program.

Step One: 

• Please complete, sign, and return your application. 
• Please call us at 410-964-1944 if you have any changes in your information, so we can update your application. 
• Due to program limitations, we have a waiting list in all counties. 
• Please include a copy of your SSI/SSDI award letter with this application.

Step Two: 

• When your application comes up for review, a Patient Care Coordinator will call you to set up a phone interview and obtain additional information that will determine your eligibility for the program.

Step Three: 

• If you are accepted, the Patient Care Coordinator will send a referral with your information to a volunteer dentist.

Step Four: 

• You will be contacted by the 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 the program. 

Fax: 1-410-964-9978

               OR

Maryland Foundation of Dentistry 

         8901 Herrmann Drive

         Columbia, MD 21045

Please call 410-964-1944 if you have any questions and we would be more than happy to help!