~HSCFDC Documentation/Monitoring System~ Dental Exam Used to determine and document child dental health status, and to track compliance with recommended schedule of well child oral care. Also documents assessed need for further examination or treatment to maintain oral health, if indicated. Program Area: 1304.20 Child Health and Development Procedures Filled Out By: Parent and Dental Provider Title of Form: Related Policy:
Timeline:
Specific Directions:
Submitted To: Timeline: Filed In:
Form mailed to parent in June. If child selected after start of school-year, form is given to parent by teacher at orientation. 1) Initial dental examination required not more than 6 months before or not later than 90 days after enrollment. 2) Parents must schedule their dental appointment and take form with them to their dental visit if upcoming, have dentist complete, then forward to Head Start, or 3) If a dental exam was completed within the 6 months prior to enrollment, parent must complete top portion of physical exam form and sign the authorization to release their child’s dental records to Head Start, then submit form to their dental provider to complete. HSM Submit to HSM as soon as received; due within 90 days of enrollment. White/original – HSM
Note: For duplicate or triplicate forms, please note where each copy of the form is filed.
Yellow – Teacher Pink – HSM if follow-up
Revised 4/2011
DENTAL EXAM HEAD START CHILD & FAMILY DEVELOPMENT CENTERS, INC. Center:_______________________
Child’s Name: ___________________________________________________
DOB: ____________________
Address: ___________________________________________ City/State/Zip: _________________________________ Parent/Guardian: ______________________________________________________________ I authorize ________________________________ dental office to release my child’s dental exam records to complete this form for Head Start. Parent signature/date: _________________________________________________________ Please indicate method of payment (circle): Medical Assistance/BadgerCare / Dental Insurance / Personal Funds -No insurance or MA
Service Provided
Indicate Follow-Up Care Needed
Date Provided
Date Provided
Examination Prophylaxis Fluoride Treatment X-Rays Emergency Treatment Oral Hygiene Instruction Does this child take a fluoride supplement or receive fluoride from their drinking water? (please circle) Other Dentist: Please retain the pink copy of this form if follow-up care is indicated. When the follow-up care is completed, please complete pink portion and mail to Head Start.
Please check one: _____ No further work is needed at this time. _____ Further dental treatment is needed. Next appointment date: _____________________________ Head Start will pay up to $75 toward the initial exam if the child is not covered by Medical Assistance or insurance. Head Start will only be responsible for payment of bills that have received prior written authorization for payment before treatment begins. Head Start must receive an invoice from your office to make payment. Please mail exam form and invoice to: Head Start Central Office, 333 Buchner Place, La Crosse, WI 54603. Telephone 608/785-2070. Dentist’s Name-Please Print:___________________________________________________ Clinic Name/Address: ________________________________________________________ ________________________________________________________ Telephone: ___________________________________
Dentist’s Signature: _________________________________
Thank you for serving Head Start children !! White – Office/HSM
Yellow – Teacher
Pink – Dentist if follow-up indicated
rev.6/11
