Author: Dylan Davis

Coming soon to your school!!!
The Bethany for Children & Families
Give Kids a Smile Mobile Dental Clinic
We provide oral health education, dental exam, teeth cleaning, fluoride and sealants if needed. Participants also receive toothbrush/floss.
Please fill out the permission form CLEARLY, including insurance information & return pages 5 & 6. New form needed EACH YEAR.

OR fill out online at epatientcenter.com
using the password “Bethany” (capital B)

*** If filling out for multiple students you may need to clear the cookies/cache on your browser, use an incognito/private mode or different electronic device. ***

Scan to fill out form

If you have any questions OR changes in health history please contact your school nurse or the GKAS Dental Program Supervisor, Melody Mosenfelder: Phone: (309) 581-6211 or Email: mmosenfelder@bethany-qc.org

———TEAR OFF AND KEEP THIS PAGE FOR YOUR RECORDS———

1

———TEAR OFF AND KEEP THIS PAGE FOR YOUR RECORDS———

2

GIVE KIDS A SMILE
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
Dentists participating in the Give Kids a Smile program may be required by applicable federal and state law to main the privacy of your health information. Protection of patient privacy is important to participants in the Give Kids a Smile program. This notice summarizes the privacy practices that will be followed by participants in the Give Kids a Smile program, and your rights concerning your health information. This Notice will apply to health information collected in connection with the Give Kids a Smile program and will remain in effect until replaced.
You may request a copy of the Notice of Privacy Practices at any time. For more information about the privacy practices, or for additional copies of this Notice, please contact Bethany for Children & Families at (309) 797-7700.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment. For example, we may use or disclose your health information to another dentist, physician, or other health care provider providing treatment to you.
Your Authorization: Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person involved in your treatment to the extent necessary to help with your health care.
Persons Involved in Care: We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.
PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. Contact us at (309) 797-7700 for assistance in reaching the dentist or facility holding your health information.
Disclosure Accounting: You may have the right to receive a list of instances in which your health information was disclosed for purposes other than treatment or certain other activities for the last six years, but not before April 14, 2003.
Restriction: You may request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You may request that we communicate with you about your health information by alternative means or to alternative locations. We may agree to reasonable requests.
Amendment: You may request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.
QUESTIONS & COMPLAINS
If you want more information about our privacy practices or have questions or concerns, please contact us at (309) 797-7700. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about your health information, or to have us communicate with you by alternative means or at alternative locations, you may contact us at (309) 797-7700. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
———TEAR OFF AND KEEP THIS PAGE FOR YOUR RECORDS———

3

GIVE KIDS A SMILE
Silver Diamine Fluoride Consent Form (SDF)

Silver Diamine Fluoride (SDF) is an antibiotic liquid. We use SDF on cavities to help stop tooth decay from growing. We also use it to treat tooth sensitivity. Treatment with SDF does not eliminate the need for dental fillings or crowns to repair function or esthetics. While SDF can treat the bacteria that causes tooth decay, it will not restore the tooth structure that has been affected by the disease process. You may still require restoration of the teeth such as fillings, crowns or possible nerve treatment. Repeat applications of SDF have been shown to provide the best results; one application can stop decay by up to 70%. If the dentist prescribes additional applications we will return to your student’s school to apply additional applications.
Benefits of receiving SDF: SDF can help stop tooth decay, SDF can help relieve sensitivity, SDF can postpone the need for traditional dental treatment, SDF can delay or eliminate the need for sedation/general anesthesia to complete dental treatment in young children and adults
Alternatives to SDF Include but are not limited to: No treatment, Placement of fluoride varnish, Restorative dental treatment such as fillings, crowns, nerve therapy
Most Common Risks related to SDF Treatment: The affected area will stain black permanently. Healthy tooth structure will not stain. Stained tooth structure can be replaced with a filling or a crown. Tooth-colored fillings and crowns may also discolor if SDF is applied to them. Normally this color change is temporary and can be polished off. If accidentally applied to the skin or gums, a brown stain may appear that causes no harm and will disappear in 1-3 weeks . You may notice a metallic taste, this will go away rapidly. If tooth decay is not arrested, the decay will progress. In that case the tooth will require further treatment, such repeat SDF application, a filling or crown, root canal treatment, or extraction. These side effects may not include all of the possible situations reported by the manufacturer. If you notice other effects, please contact your dental provider.
Most Common Side Effects: With the application of Silver Diamine Fluoride (SDF) on top of a cavity will turn the cavity portion of the tooth dark. If SDF comes in contact with skin and/or gums, temporary discoloration will occur that may take up to 1-3 weeks to go away. If SDF is placed on a tooth that has a tooth colored restoration, discoloration may occur. The front teeth will be avoided if possible.
Authorization for Dental Treatment: I authorize The Give Kids a Smile Program with Bethany For Children & Families and their associates to provide and/or administer the dental service Silver Diamine Fluoride to my student, if their associates determine in their professional judgement, necessary or appropriate in my student’s care. I understand that repeat applications of SDF have been shown to provide the best results. I am informed and fully understand that there are inherent risks involved in the administration of any drug, medicament, antibiotic, or local anesthetic. I am informed and fully understand that there are inherent risks involved in any dental treatment. I understand that my student should not be treated with SDF if they are allergic to silver, or if they have painful sores or raw areas on my gums (i.e., ulcerative gingivitis) or anywhere in their mouth (i.e., stomatitis). I realize that it is mandatory that we follow any instructions given by the dentist and dental office staff. Alternative treatment options, including no treatment, have been provided. No guarantees have been made as to the results of treatment. I understand the most common risks/side effects associated with SDF that are stated above. ***Colored pictures can be seen on our website at https://www.bethany-qc.org/give-kids-a-smile***

I CERTIFY THAT I HAVE READ AND UNDERSTAND THIS PAGE and authorize Bethany for Children & Families to treat my student with Silver Diamine Fluoride if needed. Please sign on page 6.

Photos Courtesy of Elevate Oral Care

———TEAR OFF AND KEEP THIS PAGE FOR YOUR RECORDS———

4

GIVE KIDS A SMILE — PERMISSION FORM

PLEASE PRINT CLEARLY & RETURN TO SCHOOL

M

F

Student’s First Name

Student’s Last Name

Date of Birth: Month/Day/Year

Gender

Home Address

City

State

Zip Code

Parent/Guardian First Name

Last Name

Phone

Email Address

Emergency Contact Name

Relationship to student

Emergency Contact Phone

(If other than Parent/Guardian)

Daycare/School Attending

Homeroom teacher

Grade Level

Primary Insurance Provider MEMBER ID/INSURANCE#: PLEASE PLACE IN BOXES ABOVE
Secondary Insurance (if any): ______________________________________

What race do you
consider your student? (needed for grant purposes)

My student’s most recent REGULAR DENTAL VISIT (cleaning, exam, fluoride) was:

What type of DENTAL INSURANCE does your student have? (check all that apply)

White

Private dental insurance

0-5 months

Black/African American

IA Medicaid/Delta Dental /Hawk-i

6 months or more

Hispanic/Latino

Medicaid (Medical Card, Title 19)

Never seen a dentist

Asian

Envolve/Meridian

Unsure

American Indian/Alaskan Native

Dentaquest/Molina/BCBS/Aetna

Has your child/teen been seen
in the Give Kids a Smile
Mobile Dental Clinic before?

Native Hawaiian/Pacific Islander

Other

TURN
PAGE
OVER

Middle Eastern/North African

None

Yes

2 or More Races

Please place Medicaid # in boxes above

No

For Office Use Only: HFS-IL says: Molina/BCBS/Aetna/All Kids/Meridian/Youthcare/Other: _______________
Verified Elig.: Dentaquest Envolve MCNA Delta Hawk-I other: __________ Unable to find:_______
Last Exam Date: ____/_____/_______ Sealants: Y or N SDF: Y or N (History of Sealants/SDF on back)

5

GIVE KIDS A SMILE — PERMISSION FORM

PLEASE CHECK IF YES

Needs an antibiotic before a dental procedure.

For Office Use Only

Anemia

Asthma

Bleeding Disorder

Cancer

Chronic Sinusitis

Drinks Bottled Water

Drinks City or Well Water (circle)

Metal Allergy

Head Injury

Heart Condition

Medication — Please list

Sealants Placed:

SDF Placed:
Tooth#____
Date: ___/___/_____
Tooth#____
Date: ___/___/_____
Tooth#____
Date: ___/___/_____
Tooth#____
Date: ___/___/_____
Tooth#____
Date: ___/___/_____

Nut Allergy

Latex Allergy

2

_____/_____/_______
_____/_____/_______
_____/_____/_______
_____/_____/_______
_____/_____/_______
_____/_____/_______
_____/_____/_______
_____/_____/_______

Tobacco/drug use

3

Pregnancy

14

Speech Difficulties

15

Fainting/Dizziness

18

19

Hearing Difficulties

30

Diabetes

31

Epilepsy

HIV/AIDS

Concerns with mouth/teeth:

Health History Reviewed by Dentist/RDH/EFDA:
Dentist initials: _____ RDH/EFDA initials: _____

____________________________

PLEASE READ THE CONSENTS BELOW:

I give permission for my student to receive dental treatment and allow the school nurse, school representative, and dental provider to access their dental record.
I give permission to Bethany for Children & Families to phone, text and/or email me regarding my student’s health information.
I understand that in the rare circumstance that Bethany for Children & Families needs to transport my student from his/her school to the mobile dental clinic I will be contacted for verbal consent. (There are times that we split the day with a nearby school and your child may need to be transported by an authorized Bethany representative to the location of the mobile dental clinic.)
I give permission for Bethany for Children & Families to release, obtain, or exchange information manually and/or via an electronic platform with the I-Smile Program and/or other dental provider.
I give permission for my student's sealants to be checked and resealed if needed. (These are called IDPH Quality Assurance Audits.) They are performed by professional providers that may need to return to my student’s school to recheck his or her sealants and reseal if needed.
Permission and acknowledgments are valid 12 months from the date of signature. Any changes in your student’s health history should be reported to the GKAS Program at 309-581-6211 or mmosenfelder@bethany-qc.org.
My signature grants permission for the above consents and authorizes the dental provider to treat and bill for services performed in the mobile dental clinic. I have received a copy of the privacy practices.
Signature for “YES”: _______________________________ Date: ___________
Signature for “NO”: ________________________________ Date: ____________

SDF Consent: I have read and understand the risks of Silver Diamine Fluoride (SDF) application and authorize the application and reapplication of SDF if my student would benefit from the treatment. (Benefits and risks are on page 4).
Signature for “YES”: _______________________________ Date: ___________
Signature for “NO”: ________________________________ Date: ___________

6