Elders Dental Application-Outside CHSDA

The Elders Dental Program can only be accessed one (1) time within the current calendar year.

Since the Elder resides outside the LTBB 27-county service area, they may utilize a dental provider of their choice and will be eligible for a maximum benefit of $2,400 per calendar year.

-IMPORTANT NOTE: The Elder must discuss with their provider about receiving payment from the Elder's Dental Program. If they do not accept payment from the program, the Elder will be responsible for all payments, and the program will reimburse them upon proof of payment to the dentist

A Treatment Plan from the dentist must be submitted with the application

Anything deemed cosmetic in nature will not be covered by the program. This includes but is not limited to, dental implants, orthodontics, and specialty coatings.

The Elders Dental Program is considered the PAYER OF LAST RESORT. This means all dental/medical insurance must be billed prior to the Elder's Dental Program issuing payment.

The Elder is responsible for completing and submitting this application in its entirety including submitting any dental insurance information, the treatment plan, and the Release of Information Agreement

If approved, the approval will be valid for 6 months from the date of the approval letter or until the end of the calendar year. If you do NOT use your benefit in the allotted time, the funds will be released back into the program, and you will need to reapply to access funds.

Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address

Phone number *

Preferred contact method *

Enrollment number *

Date of Birth *

Payment method: *

Direct Bill

Reimbursement

I UNDERSTAND THAT FAILURE TO FOLLOW THESE INSTRUCTIONS WILL RESULT IN MY APPLICATION BEING DENIED. I ALSO UNDERSTAND IF I PROVIDE FALSE INFORMATION CAN RESULT IN REFERRAL TO THE PROSECUTING ATTORNEY FOR FRAUD, AND/OR RECOVERY OF FUNDS PAID ON MY BEHALF.