bbsmiles.orgBridging Brighter Smiles – Enrollment

Form Enrollment Form bbsmiles 2020-05-06T15:15:42-05:00 Bridging Brighter Smiles Inc. Enrollment Form Questions? Please Feel Free to Call (262) 896-9891 Visit our website | SDF Consent FormEnglish Español Hmoob Bridging Brighter Smiles Inc. Enrollment Form School District * School Name * Student Info - Please use Legal Name Dependent * First Middle Last Date of Birth * MM slash DD slash YYYY Gender Assigned at Birth * Gender Assigned at Birth Male Female Other Decline to Answer Parent/Guardian Info - Please use Legal Name Parent/Guardian * First Middle Last Primary Phone * Email * Address * Street Address City State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific State ZIP Code Insurance Info Select Insurance Type BadgerCare / Forward Health (We ACCEPT the BadgerCare/Forward Health Card!) No Dental Insurance (See Coverage Information Below). Funds made available through your FSA/HSA account may be utilized as a form of payment, please check with your carrier for specific terms and conditions. Other Private Dental Insurance (We do not accept private insurance, see coverage information below). Funds made available through your FSA/HSA account may be utilized as a form of payment, please check with your carrier for specific terms and conditions. Please click here to read Bridging Brighter Smiles Coverage Information/Fees. I acknowledge that I have read and/or received Bridging Brighter Smile’s Coverage Information/Fees. * Yes Student Health History Does your dependent have any allergies? (Bridging Brighter Smiles is latex free) * Yes No If Yes, Please Explain Has your dependent been diagnosed with a physical or mental disability? * Yes No If Yes, Please Explain Does your dependent use medicine prescribed by a doctor? * Yes No If Yes, Please Explain Does your dependent require an antibiotic prior to dental procedures? (i.e. due to a heart condition). * Yes No If Yes, Please Explain Authorization Please click here to read Bridging Brighter Smiles, Inc.’s Notice of Privacy Practices. I acknowledge that I have read and understand the Notice of Privacy Practices. I understand that I may get a copy of the Notice of Privacy Practices by visiting the Bridging Brighter Smiles, Inc.’s website at http://bridgingbrightersmiles.org/forms/ , or from contacting the visit coordinator at any school location Bridging Brighter Smiles provides care. * Yes I confirm that I am the legal guardian of the above student and understand that by signing this form, initial and ongoing preventative dental care treatment will be provided for my dependent. This consent is good for two school years. I have the ability to dis-enroll at any time by written withdrawal of consent. * Yes Electronic Signature I understand that by selecting "I agree" below, this constitutes a legal signature. I authorize BadgerCare/Medicaid insurance payments for services rendered to be forwarded to Bridging Brighter Smiles, Inc. I agree to pay any BadgerCare/Medicaid copays. If my dependent is not insured through BadgerCare/Medicaid insurance, I agree to pay the standard fees for services rendered (see Coverage Information) directly to Bridging Brighter Smiles, Inc. * I Agree First Name * Last Name * Date * Copyright © 2019. All Rights Reserved. Bridging Brighter Smiles Inc. Page...