Bridging Brighter Smiles – Enrollment Form

School District*

School Name*

Student Info - Please use Legal Name

Dependent*

First Middle Last

Date of Birth*

Gender Assigned at Birth*

Parent/Guardian Info - Please use Legal Name

Parent/Guardian*

First Middle Last

Primary Phone*

Email*

Address*

Street Address City State ZIP Code

Insurance Info

Type of Dental Insurance*

BadgerCare/ForwardHealth
No Insurance
Other

*Bridging Brighter Smiles does not accept private insurance. Funds made available through your FSA/HSA account may be utilized as a form of payment, please check with your carrier for specific terms and conditions Please see below to read Bridging Brighter Smiles Coverage Information/Fees. Please click here to read Bridging Brighter Smiles Coverage Information/Fees

All students who do not have a family dentist are welcome to enroll. If you do not have BadgerCare/ForwardHealth, preventative services will be donated charitably to your student. For more information please contact Bridging Brighter Smiles.

Type of Dental Insurance*

BadgerCare/ForwardHealth
No Insurance
Other

Type of Dental Insurance*

BadgerCare/ForwardHealth
Blue Cross Blue Shield
ICare
Molina
Children's Community Health Plan
United Healthcare of Wisconsin
MHS Health WI
No Insurance
Other

*Bridging Brighter Smiles does not accept private insurance. Funds made available through your FSA/HSA account may be utilized as a form of payment, please check with your carrier for specific terms and conditions Please see below to read Bridging Brighter Smiles Coverage Information/Fees.

Type of Dental Insurance*

BadgerCare/ForwardHealth
Blue Cross Blue Shield
ICare
Molina
Children's Community Health Plan
United Healthcare of Wisconsin
MHS Health WI
No Insurance
Other

Please click here to read Bridging Brighter Smiles Coverage Information/Fees.

I acknowledge that I have read and/or received Bridging Brighter Smile's Coverage Information/Fees. I agree to pay the standard fees for services rendered (see Coverage Information) directly to Bridging Brighter Smiles, Inc.*

Yes

Student Health History

Does your dependent have any allergies? (Bridging Brighter Smiles is latex free)*

Yes
No

If Yes, Please Explain

Has your dependent been diagnosed with a physical or mental disability?*

Yes
No

If Yes, Please Explain

Does your dependent use medicine prescribed by a doctor?*

Yes
No

If Yes, Please Explain

Does your dependent require an antibiotic prior to dental procedures? (i.e. due to a heart condition).*

Yes
No

If Yes, Please Explain

Authorization

Please click here to read Bridging Brighter Smiles, Inc.’s Notice of Privacy Practices. I acknowledge that I have read and understand the Notice of Privacy Practices. I understand that I may get a copy of the Notice of Privacy Practices by visiting the Bridging Brighter Smiles, Inc.’s website at http://bridgingbrightersmiles.org/forms/, or from contacting the visit coordinator at any school location Bridging Brighter Smiles provides care.

Yes

(OPTIONAL) ADDITIONAL ADULT. I AM GIVING CONSENT FOR BRIDGING BRIGHTER SMILES, INC. TO DISCUSS AND DISCLOSE THE ABOVE STUDENT’S CLINICAL INFORMATION WITH:

Authorized Person's First Name

Last Name

Electronic Signature

I confirm that I am the legal guardian of the above student and understand that initial and ongoing preventative dental care treatment will be provided for my dependent. I authorize BadgerCare/Medicaid insurance payments for services rendered to be forwarded to Bridging Brighter Smiles, Inc. If in the future Medicaid requires copays, I agree to pay. I have the ability to unenroll at any time by written withdrawal of consent.*

I Agree

First Name*

Last Name*

Date*

Bridging Brighter Smiles Inc. Enrollment Form

Student Info - Please use Legal Name

Parent/Guardian Info - Please use Legal Name

Insurance Info

Student Health History

Authorization

(OPTIONAL) ADDITIONAL ADULT. I AM GIVING CONSENT FOR BRIDGING BRIGHTER SMILES, INC. TO DISCUSS AND DISCLOSE THE ABOVE STUDENT’S CLINICAL INFORMATION WITH:

Electronic Signature