For Patients
Grant Application
Welcome to our Dental Grant Application page. We’re dedicated to helping eligible individuals access essential dental care, and we invite you to apply. Please take a moment to review the guidelines and restrictions before proceeding.
If you are ready to apply, the application process includes four required steps:
Review our Privacy Notice, complete a HIPAA Authorization Form, and a Patient Consent Form—all of which must be completed, signed, and submitted along with the Grant Application Form on this page.
All four items are necessary to process your request for funding, so please read carefully and submit each part accurately to avoid delays.
Dental Grant Application
1. Privacy Notice
Our Privacy Notice outlines how we handle and protect the personal information you share with us during the grant application process. It explains our commitment to safeguarding your privacy and details the steps we take to ensure your information remains confidential, secure, and used solely for eligibility and successful dental treatment purposes. By reading this notice and signing the form below, you acknowledge our careful management of your data, assuring you that we follow strict privacy standards to protect your information. Review our Privacy Notice.
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2. HIPAA Authorization Form
The HIPAA Authorization Form allows us to securely handle any medical information shared by you or your dental provider as part of your grant application. Although we are not involved in your actual dental treatment, this authorization ensures that any health information provided is protected in compliance with HIPAA standards. This form is a standard requirement, allowing us to review relevant medical details safely and responsibly as part of the grant approval process. Your privacy and the confidentiality of your health information are of utmost importance to us.
3. Patient Consent Form
Our Patient Consent Form is essential for applicants to sign because it confirms that you understand and agree to the terms of applying for our dental grant. By signing, you give us permission to process your application and contact your dental provider if necessary. This consent ensures that you’re fully informed about the application steps and allows us to work effectively with all parties involved to evaluate your eligibility for funding. Review and fill out HIPAA Authorization and Patient Consent Form (combined page for single submission).
4. Dental Grant Application Form
As the final and most important step, please complete the following grant application form with your personal information, ensuring all sections are filled out as thoroughly as possible to help us accurately assess your eligibility for funding.
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