Application Form

 

 Introduction Letter For Application

 
Please read all of these documents and either mail in or fax these back. It is critical for all required documents be provided before your application can be considered.
 
Important to know: We ask that you participate financially in your dental health care. You must determine how much you can participate financially and provide that amount to The Giving Neighbors. The amount you provide will go towards your invoice if you are accepted to the dental program. The dollar amount you choose to pay should be the most you can provide and should be provided prior to making your first appointment. This amount will be asked for during the phone interview when we complete the review of your application.  
 
Remember, if you are accepted, all funds available to you from The Giving Neighbors are a gift. Treat it as such.
 
When you submit your application you are agreeing to the following conditions:
 
The dentist may not be able to provide treatment, if that happens the dentist’s recommendation must come back through The Giving Neighbors to determine if further evaluation or treatment can be considered.
 
If you cancel the appointment you will not be able to be considered for future participation in the program.
 
If you are late to your appointment you will move to the end of the line and may not be able to be seen at all. Rescheduling of the appointment may not be possible.
 
Please do not bring children with you to your appointment and a limit of one other adult can come with you.
 
If you have any questions please call.
 
Regards,
 
C. Gibson
Executive Director
Phone: 903-875-1799
Fax: 903-875-1801
 
 
 
 
Application Navarro County
 
Full Name:                                                                                                  Date:
 
Home Phone:                                                    Work Phone:                          Date of Birth:
 
Current and Verifiable Address ( Street, City, State)
 
Employer’s Name:                                             Employer’s Phone Number:
 
Employer’s Address (Street, City, State)
 
Your direct supervisor/manager name and phone number:
 
If Self Employed
 
Date of last job performed:                                  Contact/Reference of last job performed
                                                                        (Name and Phone number):
 
Address (Street, City, State)
 
 
Personal Information
 
Marital Status: Married   Single
 
Spouses Full Name:                                                       Date of Birth:
 
Spouses Employer’s Name:                                            Employer’s Phone Number:
 
Employer’s Address (Street, City, State)
 
 
Direct supervisor/manager name and phone number:
 
If Self Employed
 
Date of last job performed:                                  Contact/Reference of last job performed
                                                                        (Name and Phone number):
 
Address (Street, City, State)
 
How many live in your household? _______                 How many dependants do you have: _______
How many in your household are working? ________
 
If Unemployed are you actively looking for employment?     Yes         No     
 
If yes, how many applications have you submitted in the past month?
 
 
Do you attend a local church regularly? If yes, please provide name of church _______________________________.
 
 
Have you asked for or received financial assistance from your church? If yes, when and for what?
 
 
Have you asked for or received any assistance from other local organizations, if so, which ones?
 
 (Page 1)
  
The below information must be provided in full or application is not completed.
These documents can be faxed to 903-875-1801 or you can mail them to PO Box 551, Corsicana, TX 75151.
 
 
Net Monthly Income (Total of all persons working and living in your household.) _______________
 
You are requesting Assistance for Dental, Prescriptions or Medical.
 
ARE YOU ON MEDICAID?___________ARE YOU ON THE STAR HEALTH OR STAR PLUS PROGRAM?
 
DO YOU HAVE INSURANCE?           If yes, with what company?
 
Describe in detail the circumstances surrounding the application. Why you need assistance. Please take time to provide details.
 
 
 
 
 
 
 
 
Provide the following documentation:
a) Copy of the most recent pay stub or any income statements for every person in your household.
 
b) Copy of drivers license or government issued id.
 
c) Copy of any recent utility bill in your name and sent to your legal residence.
 
d) Copy of recent document to show monthly amount you pay for your housing (landlord or Mortgage Company) and to whom it is paid. Valid contact name and telephone number for validation must accompany this. 
 
e) If you or any member of your family is receiving Social Security Disability or Social Security Income, a copy to verify these incomes showing your monthly benefit amount must be provided.
 
f) If some of the above are not available submit a letter of reference indicating need with a valid contact name and number to confirm.
 
g) Itemized list of current monthly income and expenses: i.e. list mortgage payment, food, utilities, medications, etc. (See form)
 
h) Copy of most recent bank statement
 
(Page 2)
 
TOOTH ACHE SCREENING QUESTIONS
 
 
Your Name:                                                                                         Date of Birth:

1. How many medications are you taking presently?  IMPORTANT – PLEASE LIST ALL YOUR MEDICATIONS:
2. If you accidentally cut yourself, do you have a difficult time controlling bleeding?  Are you taking Coumadin, warfarin, blood thinners, baby aspirin, if so how much?


3. Do you have osteoporosis or have you taken bisphosphanates in your lifetime? If so, when, how much, orally or intravenously?  Common examples: Boniva, Actonel.
4. Do you smoke?                            How much? 
5. Are you immunocompromised in any way (have HIV, AIDS, Hep A,B,C, diabetes, cancer, anything else I need to know about?).

Diabetic?         Which type?             Would you say your blood sugar is controlled/regulated?                 When was the last time you checked your blood sugar level and what was it?
 

6. Ever had heart event?            High or low blood pressure?             Last time BP was checked AND WE NEED THE NUMBERS (VERY IMPORTANT)          

7. Stress-related asthma?                          Any severe allergies?

8. Ever had a grand mal full-fledged seizure?

B. DENTAL QUESTIONS

1. Where are you experiencing discomfort?              Tooth pain or gum pain?                
Which tooth or teeth is it?           (Starts UR-1 -> ends LR-32).  Also 8,9 are upper front 2 teeth  24,25 are lower front 2 teeth
How many teeth are you requesting help with?

What is the matter with these teeth?

2. How long have you been in pain?

3. Has it kept you up at night?

4. Is it shooting/shocking    Or throbbing/dull?

5. Does pain last longer than 5 seconds w/ which of these?          Hot, Cold, Pressure, Sweets

6. Can you put your finger on the one that hurts w/ certainty?

7. Does it move very much?

8. Have you noticed any small puss pimple pockets on your gums or around the tooth?

9. Can you open your mouth all the way?
 
10. Do you have a lot of swelling? 

11. Do you have a local dentist?             If yes, who is it? ____________________________

12. Do you owe a local dentist any money?            If yes, who and how much?
 
 
IF YOU ARE NOT SURE HOW TO ANSWER ANY QUESTIONS, PLEASE CALL US. WE WILL BE GLAD TO HELP YOU.

 (Page 3)
                 Monthly Income and Expense
 
Date:
 
Total Monthly Income for all adults (over 18) residing in the home.
List the names of all working adults living in the home.
                                   
Your name:                                                       Income Amount and Source:
 
Spouse Name:                                                  Income Amount and Source:
 
Retirement Benefit: ______________
Other Income sources: SSI _____________               WIC ______________
Food Stamps ______________                                   Child Support _______________   
Disability ________________                                    Other ________________
 
Monthly Expenses:
 
Rent/Mortgage _____________          Gas/Electric/Water _______________
Telephone bill _____________            Cell Phone   _______________
Cable/Satellite _____________           Car payment ______________
Car Insurance ______________          Health Insurance ___________
Medical Bills/Prescription Drugs ____________________________  
Internet Service _________________Groceries_______________
Child Support ________________ Gas_________
Other _____________                       
 
Dependents living in household (under 18) ___________
 
 
Signed and Dated by Applicant (s)
 
Print Name :___________________________ Signature:_______________________
 
Print Name: ___________________________ Signature: _______________________
 
 
(Page 4)
 

 Permission Form

 
 
DATE:
 
To Whom It May Concern:
 
I (Name)                                              give you permission to discuss my medical and financial situation concerning my dental care with The Giving Neighbors.
 
This organization is working to help me get my medical/dental needs taken care of.
 
 
 
Signature: _______________________________________
 

(Page 5)