Dental OPTIONS

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DENTIST ENROLLMENT FORM

Name
Address
City
County
Zip Code
Phone Number  
Fax Number  
Email
Office Contact Person
Second Office Address
(if applicable)
City
County
Zip Code
Phone Number  
Fax Number  
Please indicate which program(s) you want to participate in: Dental For All
(reduced fees)
Donated Dental Services
(donated services)
Please indicate if you are a: General Practitioner   Specialist
How many Dental OPTIONS patients would you consider acceping during the next 12 months?
Is your office on a bus line? Yes   No
Please detail any additional information that you would like us to have:
The Dental OPTIONS program will recognize your service with a plaque.
How would you like your name to read?
*The names of participating dentists are kept confidential. Lists will not be compiled for any other programs or agencies.

Referral coordinators determine a patient's eligibility for discounted fees or donated care. The coordinator will not make a referral before contacting the dentist's office to confirm (the dentist can decline for any reason) and will maintain contact with both dentist and patient to assure that treatment is progressing smoothly.

If a patient fails to show for an appointment, the dentist may choose to discontinue seeing the patient. A second no show result's in the patient's automatic dismissal from the program.

Participating dentists do not act as an agent, employee, or authorized representative of the Ohio Dental Association or other organizations supporting Dental OPTIONS.

The ODA and other organizations sponsoring Dental OPTIONS are not responsible for any claims against a participating dentist arising out of his or her treatment of patients under the program, nor are they responsible for any difference between the fee that a dentist normally charges and the fee actually paid by a Dental OPTIONS patient.

After the initial sign-up, a participating dentist may withdraw from Dental OPTIONS by contacting, in writing, the ODA or the Dental OPTIONS referral coordinator.

I understand the Dental OPTIONS program and am willing to provide dental care to qualified patients.