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School Based Oral Health Program Consent Form

DC Health - Government of the District of Columbia

Government of the District of Columbia School

Based Oral Health Program Consent Form

Dear Parent or Guardian:

The District of Columbia Department of Health (DC Health) sponsors preventive dental services at your child’s school through the DC School-Based Oral Health Program (SBOHP). Through this program, licensed dentists and their staff provide exams (“checkups”) and x-rays to students who have not seen a dentist in six (6) months. The services include dental cleanings, fluoride treatments, and sealants (as needed). Students that need services not offered (filling s, drillings, shots, tooth removal, or braces) at the visit will be referred to local dentists. Information from your child’s visit will be shared with the school nurse or other point of contact at the school, and with the SBOHP for the purposes of billing, treatment, follow-up, and program monitoring.

PLEASE NOTE: Children should see their dentists every six (6) months. The SBOHP services should NOT take the place of a visit to a child’s regular dentist. The dental providers will check for dental insurance coverage and the last dental visit for all children to be seen at the school, and will bill insurance for any services provided.

Please complete the form below. Required fields marked with an asterisk *

Child/Student Information

Health Insurance

Compete each section. 

This Child has private dental insurance:

Insurance Company:  _______________________________
Insurance Co. Phone: _______________________________
Employer: _______________________________
Employer Phone: _______________________________
Name of Insured Adult: _______________________________
Insured Adult’s Date of Birth: _______________________________
Member ID/Policy#: _______________________________
Group #: _______________________________
This child has the following Medicaid/Health Families insurance plan:*
Answer Required
Last Dental Visit*
Answer Required

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

Medical Information: Check each condition that applies to your child and explain in the space provided. *
Answer Required
I have read the notice on the back of this page and understand and agree to its terms. By signing, I give my informed consent for my child to receive services through the DC Health School-Based Oral Health Program. Your name is your signature*
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