APPLICATION FOR DONATED DENTAL SERVICES

---

 Step One: Complete, sign, and return the accompanying application. A patient care coordinator will call you when your application is up for review, or you will receive notification if your application is denied. Call 410-964-1944 with any changes in your information for your application to remain updated. Please include a copy of your SSI/SSDI award letter with this application.

Submit your application either by:

• Mail: Maryland Foundation of Dentistry, 8901 Herrmann Dr. Columbia, MD 21045
• Email: info@mfdh.org
• Fax: 410-964-9978

Step Two: When your application comes up for review, a patient care coordinator will call to set up a phone interview and obtain additional information that will determine if you’re eligible for the program.

Step Three: If you are accepted, the patient care coordinator will send a referral with your information to a volunteer dentist in your community.

Step Four: You will be contacted by the dentist’s office to schedule appointments. 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.

If you have any questions, contact us at 410-964-1944.