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1162050-511175Northern Kentucky Adult Dental Assistance ProgramBoone County Kenton County Campbell CountyAuthorized Consent and Guidelines Form Please read and initial each of the following statements. After reviewing and agreeing to each of the conditions, please sign and date the form at the bottom._____I understand that the goal of the Northern Kentucky Adult Dental Assistance Program is to help participants achieve oral health. I understand that the dentist determines the treatment plan to accomplish the goal of preventing dental decay and restoring the participant to good oral health. As such, the dentist is solely responsible for diagnosis and treatment. _____ I understand that after treatment is finished, any future dental needs will require a new application process with supporting paperwork. Do not call the dental provider directly unless you wish to pay out of pocket._____ I understand the importance of being on time for appointments and that failure to appear for a scheduled appointment with the dental provider, without 48 hours notice, and/or rescheduling more than one scheduled appointment will be grounds for dismissal from the program. _____ Disrespectful behavior, failure to treat office staff with respect, and participants showing signs that they are seeking services so that they will be provided with drugs are also grounds for dismissal from the program._____I agree to provide personal information that includes medical, dental and financial information.This includes my consent for the referral coordinator to obtain and share information with one or more participating dentists (including their office personnel) that is relevant to my eligibility for the Northern Kentucky Adult Dental Assistance Program. This information may come from, but is not limited to, physicians, dentists, financial institutions, and government or private agencies concerning my medical conditions, medical history and financial information _____I agree to hold harmless the Northern Kentucky Adult Dental Assistance Program and Campbell, Boone, or Kenton County Fiscal Courts, for the release of my information to third parties._____ I understand that application to the Dental Assistance Program does not assure that I am eligible for services and as such I may not be referred to a dentist for an examination or I may not be accepted as a patient following an examination._____I understand that participating dental providers are not obligated to provide donated, free services, or care in the future or to maintain me as a patient._____I understand and give consent to the Northern Kentucky Adult Dental Assistance Program to use my demographic information for marketing campaigns to promote involvement from dental professionals and potential funders. _____I agree that to the best of my knowledge the information I provided on this application is a full and accurate disclosure of my current financial status. I will notify the program coordinator if there is a change to my contact information or other relevant status._____ I will notify the program coordinator if I am referred to a specialist or must delay or stop treatment for any reason._____I understand that the Dental Program depends upon outside funding sources. Any changes in funding may result in a disruption of my treatment. Accordingly, I agree to hold harmless the Northern Kentucky Adult Dental Assistance Program and the Campbell, Boone, or Kenton County Fiscal Courts for any disruptions in my treatment._____I understand that the Northern Kentucky Adult Dental Assistance Program may terminate my participation for any reason, at any time._____I understand that annual assistance (measured yearly from July 1 through June 30) provided to me may not exceed $2,000 and that any amount that exceeds this may be responsibility of the client. I further understand that amounts in excess are the responsibility of the participant and due to the dental provider before services will be delivered.Read, agreed and signed this ______ day of ______________________, 20___.Sign:___________________________________Client Name:_______________________________________Sign:___________________________________Guardian Name (if necessary):________________________________________ ................
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