№ files_lp_3_process_7_049003
Application form establishing eligibility, medical history, income verification, and treatment priority criteria for participation in a community dental assistance program operated through a mobile clinic on Orcas Island.
Year: 2014
Region / City: Orcas Island, Washington
Organization: OICF and Medical Teams International
Program: Dental Van
Document Type: Application Form
Subject: Dental Care Assistance
Target Audience: Residents of Orcas Island seeking dental care without insurance
Eligibility Criteria: Income below 200% of the Federal Poverty Level; no dental insurance; no realistic ability to pay for urgent dental care
Services Mentioned: Extraction, Filling, Cleaning/Exam, Crown, Denture
Exclusions: No root canals performed
Submission Location: Public Library drop box marked “Dental Van”
Contact Persons: Rita Bailey; Barbara Ehrmantraut
Contact Email: [email protected]
Contact Phone: 360-298-2791; 360-376-3395
Confidentiality Statement: All information handled confidentially
Screening Guidelines: Income verification and priority based on pain, infection, or decay
Certification Requirement: Applicant signature confirming accuracy and lack of insurance
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

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