As the parent/guardian of the above-named student, I consent for him/her to receive dental services through the DC Health School-Based Oral Health Program. I understand that my child’s participation provides consent for the following:
• The dental provider to verify insurance before services are provided;
• The dental provider to bill & collect payment from any Medicaid, private insurance, or other payer.
• If I have private dental insurance, the dental provider to bill the family for any deductibles and/or copays.
• The dental provider to confidentially share my child’s clinical information with DC Health, DC Department of Health Care Finance, Medicaid Managed Care Organizations, and/or other clinical providers involved in my child’s health care.
Further, I agree to discharge, indemnify, and hold harmless the Government of the District of Columbia and any agency, employee, officer, agent or representatives thereof from all claims, demands, actions, or judgments which I or my heirs, executors, administrators, or designees may have for any and all injuries and damages, known or unknown, caused by or arising from the activities listed above.
I understand that if I fail to sign this consent form, my child will not receive any services offered under this program. I understand I may revoke this consent at any time by providing written notice to DC Health’s Oral Health Program (899 N. Capitol St. NE, 3rd Floor, Washington, DC 20002) or via email [email protected].
I further understand that until this revocation is made, the consent for services shall remain in effect for one calendar year from the date it is signed, and my child’s information will continue to be accessible by the parties listed above for the specific purposes described