Confidential Application Dental Services for Seniors

Please Mail to:

Oral Health Program, 6101 Yellowstone Road, Suite 420, Cheyenne, WY 82002

Client's Name

Address:

Birthdate:

Month:

Day:

Year:

Married:

Single:

Widow:

Widower:

YOUR MONTHLY INCOME: We require verification of income. A copy of: last year's W-2: Last pay stub: social security and /or retirement statement.

Social Security	Retirement	Property: BUSINESS/FARM RENTAL, LIVESTOCK ETC	Stocks/ Bonds	Other
$	$	$	$	$

YOUR SPOUSE'S MONTHLY INCOME (IF MARRED)

Social Security	Retirement	Property: BUSINESS/FARM RENTAL, LIVESTOCK ETC	Stocks/ Bonds	Other
$	$	$	$	$

 

Total income last year	Amount in checking	Amount in savings
$	$	$

MONTHLY MEDICAL EXPENSES:

Pharmacy	Laboratories	Hospitals	Other
$	$	$	$

I will apply any dental insurance benefits I receive to the cost of my dental treatment

The information you have provided will remain confidential with the Department of Health except in the following circumstances: The Dental Health Program (DHP) as part of the Department of Health is a covered entity. DHP may request from any state agency, insurer, group health plan, health maintenance organization or similar entity any or all of your protected health information. This information may be used or disclosed for the process of treatment, payment or healthcare operations. This is in accordance with the Health Information Portability and Accountability Act section 164.502(a)(1)(ii). Please see your Client Privacy Rights Policy for use and disclosure of your protected health information.

All information given on this confidential financial statement is true to the best of my knowledge.

Signature:_____________________________________Date:___________________________