FINANCIAL SCREENING FORM

Last First Middle PATIENT NAME:_________________________________________________________ SOCIAL SECURITY NUMBER:___________________________

Address: ________________________________________________________________________________________________________________

City: _______________________________ State: _________ Zip Code: ____________ DRIVER’S LICENCE NUMBER:_________________________

COUNTY OF RESIDENCE:______________________ Date of Birth: ________________________________ Age ______

Home Phone Number: __________________________________ Cell Number: ________________________________________

WORK NUMBER: ________________________________ SUPERVISOR’S NAME: ____________________________________________________

Last First Middle SPOUSE’S NAME: _________________________________________________________ SOCIAL SECURITY NUMBER: ________________________

*TOTAL NUMBER OF PEOPLE LIVING IN PATIENT’S HOUSEHOLD ___________ Are you covered by any Dental Insurance? ______

Income Verification

The following documents are required for discount dental services

Patient Information (or Patient’s Father) Spouse's Information (or Patient’s Mother)

Last 3 month’s Paycheck Stubs_____________ Last 3 month’s Paycheck Stubs___________

Last 3 month’s Bank Statements ___________ Last 3 month’s Bank Statements __________

W-2 VERIFICATION__________________ W-2 VERIFICATION__________________

Copy of Tax Return _________________ Copy of Tax Return__________________

Proof of Social Security or Disability Benefits_________ Proof of Social Security or Disability Benefits_________

Proof of Government Assistance_______ Proof of Government Assistance___________

UNEMPLOYMENT LETTER____________ UNEMPLOYMENT LETTER____________

Picture ID _____ Utility Bill_________ Picture ID _____ Utility Bill_________

OTHER WAGES ____________________ OTHER WAGES ____________________

HOUSEHOLD MEMBER Name	Relationship	Age Employer Income (circle one)	Totals
Weekly / Monthly / Yearly
Weekly / Monthly / Yearly
Weekly / Monthly / Yearly
Weekly / Monthly / Yearly
Weekly / Monthly / Yearly
Weekly / Monthly / Yearly

I certify the household size and income information provided above is correct. I understand that charges are calculated using

a sliding fee scale which generates my financial responsibility based on my annual income and family size.

Crown

_________________________________________ ________________

Patient or Guarantor Signature Date

For Office Use Only

TOTAL FAMILY INCOME____________________	DISCOUNT ALLOWED ____________% INCOME LEVEL __________K

Date of Financial Screening: ________________ Screener’s Initials: _____________ Patient Notified _______________

3208 U.S. Highway 41 N., Byron, Ga. 31008 Telephone: (478) 953-7770 Fax: (478) 953-7771

Patient Name: _______________________________________________ DOB: _________________________

Last First Middle Month/ Day /Year

In signing below, I confirm my understanding that:

1) IDENTIFICATION: I must provide current/valid government issued photo identification i.e.: driver’s license, state identification, or passport.

2) SLIDING FEE SCALE: Charges are calculated using a sliding fee scale which generates my financial responsibility based on my annual household income and family size. In order to determine my financial responsibility, I must provide verifiable and acceptable proof of my household income. If I do not provide acceptable proof of household income I will automatically be denied services at this clinic.

3) PROOF OF HOUSEHOLD INCOME: I must provide all documentation which applies for proof of household income. i.e.: All forms filed for most recent year’s income tax return, last three months current and consecutive pay check stubs for everyone employed in the household, and/or recent government benefits letter showing current amount of benefits. I will bring proof of income every six months from the time of my initial visit to maintain my eligibility for services.

a. Proof of Household Income Reassessment: My financial responsibility will be reassessed at least every six months at which time I will need to provide an updated proof of household income in order to re-determine my financial responsibility. When I am asked to provide acceptable updated proof of household income and I fail to provide it, I understand that I will no longer be eligible for continued services at this dental clinic.

4) REHABILITATION CENTERS AND SHELTERS: If I currently reside at a rehabilitation center or a shelter I must provide a letter (dated for the day of service) on a letterhead, at every appointment confirming my residency and employment status. I understand that if I do not provide the dated letter I will not qualify for services.

5) PAYMENT: I acknowledge that Rehoboth Life Care Ministries, Inc. requires payment based on the sliding fee scale of my household income and must be paid prior to receiving dental care services. This payment will be applied to the office visit. My appointment will be rescheduled if payment is not received at check-in. Charges will vary depending on the household income.

6) APPOINTMENT CANCELATION: I understand that Rehoboth Life Care Ministries, Inc. requires a twenty-four (24) hour notice of cancelation for any appointment (MONDAY APPTS CANCEL BY PREVIOUS FRIDAY, NOT SUNDAY). Should I fail to provide such notice, I agree to pay the $25.00 no-show fee ($50.00 if scheduled with one of our specialty providers or new patient appointment) in consideration for my lack thereof. Additionally, if the appointment was scheduled less than 24 hours before the appointment itself, I agree to pay the no-show fee in the event I cancel or no-show.

No-Show Appointments: I understand that three (3) no-show appointments within a twelve (12) month period will suspend me from the program for one (1) year.

New patient No-Show Appointments: I understand that if canceling or missing a new patient appointment it can be rescheduled once; if I cancel or miss the second new patient appointment it will suspend me from the program for one (1) year.

LATE ARRIVAL: Rehoboth Life Care Ministries, Inc. allows a 15 minute grace period for late arrival to my scheduled appointments. If I arrive more than fifteen (15) minutes late, my appointment must be rescheduled and it will be considered a no-show.

PRIVACY PRACTICES: I may review Rehoboth Life Care Ministries, Inc. Notice of Privacy Practice at any time.

AUTHORIZATION TO TREAT: I give Rehoboth Life Care Ministries, Inc. it agents and volunteer professional’s authorization to treat the patient listed herein.

I have read, understand and agree to these terms. Not abiding by these terms may result in termination of services.

Date: ____________Signature: _____________________________________ Relationship to Patient: _______________

Dental Care Program

Applicant / Patient

Circle which applies to your situation.

(Circle one) I, __________________________________________ (patient name) did or did not filed taxes last year.

Signature: ______________________________________________ Date: ________________________

(Circle one) I, __________________________________________ (patient name) do or do not have a bank account: checking/savings.

Signature: ______________________________________________ Date: ________________________

(Circle one) I, ____________________________________________ (patient name) do or do not have dental insurance that covers procedures such as dental extractions, restorations (fillings), or dental hygiene (cleanings) services.

Signature: ______________________________________________ Date: ________________________

Spouse / Significant Other

Circle which applies to your situation.

(Circle one) I, ______________________________________________ (patient name) did or did not filed taxes last year.

Signature: ______________________________________________ Date: ________________________

(Circle one) I, _____________________________________________ (patient name) do or do not have a checking/savings account.

Signature: ______________________________________________ Date: ____________________

Other Information

Patient Name ____________________________________________________ does live with me and I help him/her financially with

anything he/she may need. He/she does not work and has no income.

________________________________________________ ________________________________

Signature/Relationship Date

Car Make & Model: ________________________________________________ Year: __________________________

RLCM VOLUNTEER DENTAL CLINIC

PATIENT PRELIMINARY SURVEY

Please take the time to fill out this survey as completely as possible.

When did you last visit a dental office?

□ Less than 6 months □ Less than a year □ Between 1-3 years □ Between 3-5 years □ Over 5 years

Was it for an emergency visit (pain or broken tooth) or routine scheduled care?

□ Emergency Visit □ Routine scheduled care

What do you normally do for help when you have a toothache?

□ Use over the counter medication □ Get a new prescription medication □ Use an older prescription medication □ Use another person’s prescription medication □ Other: ____________

Where did you get the help for your toothache?

□ Private dentist office □ Public or community dental clinic □ Emergency Room □ Private doctor’s office

□ Other: ___________________________________________________________________

Does your dental health affect how or what you eat?

□ Yes, all the time □ Yes, but not all of the time □ No, Never

Do you believe that your dental health affects your overall health?

□ Yes □ No

Do you receive routine dental cleanings (hygiene) every 6 months?

□ Yes □ No If no, why? □ Lack of money □ Lack of time □ No desire to do it □ Fear of dentist

□ Other: ____________________________________________________________________

How long ago was your last dental cleaning (hygiene) visit?

□ Less than 6 months □ Less than a year □ 1-3 years □ 3-5 years □ More than 5 years

What is your age range:	10. Marital Status:

□ 18-21 □ 22-29 □ 30-39	□ Single □ Married □ Divorced

□ 40-49 □ 50-64 □ 65+	□ Widowed □ Other

Race:

□ Asian □ Black □ Indian (India) □ Latino □ Native American Indian □ White

What county do you live?

□ Houston □ Peach □ Taylor □ Crawford □ Other : __________________________________

How would you rate your oral health?

□ Very poor □ Poor □ Average □ Fair □ Good □ Very good □ Excellent

How many cavities have you had in your lifetime?

□ None □ 1-3 □ 4-7 □ More than seven □ Not sure

How many adult teeth have you had pulled (extracted) in your lifetime?

□ None □ 1-3 □ 4-7 □ More than seven □ Not sure

Why did you have them pulled instead of having them restored (fixed by filling, root canal, crown etc.)?

□ No money to save the teeth □ I did not think I had any options □ I preferred extraction □ Not sure

Did you try to replace the missing teeth (with a denture, partial, bridge etc.)?

□ Yes □ No □ I wanted to, but could not afford it □ Other:__________________________________

What is your smoking status?

□ I have never smoked □ I currently smoke □ I used to smoke

How often do you use tobacco products on an average day?

□ Two times or less □ Three to five times □ Six to ten times □ More than ten times

Do you drink alcoholic beverages? □ Yes □ No

How often do you drink alcoholic beverages?

□ Every day □ Three to five times a week □ Special occasions □ Only on the weekends

What is your highest education level?

□ Less than or some high school □ High School Grad/GED □ Technical/Vocational □ Some college

□ College Grad □ Post Grad/Professional Degree

Household Income: □ Under $5000 □ $5000-$9,999 □ $10,000-$14,999 □$15,000-$24,999

□	$25,000-$34,999 □ $35,000-$49,000 □ More than $50,000