Lifelong Dental Program

Lifelong Dental Program The Lifelong Dental Program (LDP) is a comprehensive oral health access program for low income individuals living with HIV/AID...
Author: Corey Harvey
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Lifelong Dental Program The Lifelong Dental Program (LDP) is a comprehensive oral health access program for low income individuals living with HIV/AIDS who reside in King, Island, and Snohomish Counties. Services are offered at select, contracted providers in each of these three counties. Funding for this program has been made available as a result of grant awards from the U.S. Department of Health and Human Services, Health Resources and Services Administration, and Public Health – Seattle King County. To be eligible for the program, clients must: o Be a resident of King, Island, or Snohomish County o Have an income less than 400% of Federal Poverty Level o Be HIV positive Please work with your case manager to complete an LDP application. If you do not have a case manager, you may download the application material from the Lifelong website and contact a LDP coordinator for assistance as needed. The application form must be fully completed in order to be enrolled in LDP. Please include documentation required for eligibility (proof of income, proof of residency, and HIV status verification) when submitting your application. Once eligibility is determined, you will receive an enrollment letter and a phone call from a LDP Coordinator to set up your initial dental appointment.

Lifelong Dental Program · PO Box 80547 · Seattle, WA · 98108 · P. 206-957-1716 · F. 206-323-0158

Lifelong Dental Program Application Application (2 pages) must be fully completed. Any unanswered questions will result in a delay of processing or a denial.

General Information

Check here if you have applied to or been enrolled in the LDP previously.

Full Name (printed):

Date of Birth:

Street Address:

City:

Zip:

Mailing Address (if different):

City:

Zip:

County:

King

Snohomish

Island

Phone #:

O.K. to Send Mail?

Yes

No

Message type: No Message

Gender:

Female Male Transgender (M– F) Transgender (F-M) Case Manager Name/Agency:

Any

Discreet

Name Only

Social Security Number:

Case Manager Phone #:

Medical and Dental Information Current Dentist/Dental Clinic Name: Do you have Dental Insurance? Date of Last Dental Exam:

Yes

No

Unknown

If yes, name of Dental Insurance: ________________________

HIV Physician Name:

Medicaid:

Yes

No

Medicare:

Yes

No

Are you disabled?

HIV Physician’s Phone:

Yes

No

Most Recent CD4/date: _______________________ , _____/_____/________ Most Recent Viral Load/date: __________________, _____/_____/_________ Housing and Household Information Household Size: Check all that apply:

Number of Dependents Under 18: Homeless

Single Adult Living Alone

Single Parent Living with Children