November 8, 2019 Dear Parent or Guardian: We are very pleased to announce that our annual Dental Screening will take place on Friday, December 2, 2019 at The Gramon School. Students will have the opportunity to obtain a dental examination and preventative dental care. Dental services are graciously provided by the KinderSmile Foundation and Dr. Nicole McGrath and her staff. The results of the screening will be sent home following your child’s evaluation. Dr. McGrath has been a member of the Communication, and the Oral Health Coalition Committees of the NJ Dental Association since 2008. She has been recognized for her commitment and spirit of volunteering by multiple organizations over the past two decades. Dr. McGrath is a Board Member of Advocates for Children of New Jersey, the President of Essex County Dental Society, and the Chair of the Membership Council of New Jersey Dental Association. She became a Fellow of the American College of Dentists—the oldest national honorary organization for dentists—with the Class of 2017. Fellows of ACD have exemplified excellence through outstanding leadership and exceptional contributions to dentistry and society. If you would like your child to participate in the dental screening program provided by KinderSmile, please complete and sign the enclosed consent and permission forms and kindly return these to the Gramon School by Wednesday, November 20, 2019. If you have any additional questions, please do not hesitate to contact our health office. As always, your child’s health and wellbeing are our primary concerns. Kind regards,

The Gramon Family of Schools Health Office Nursing Department of the Gramon Family of Schools T.973-808-9555 ext.620 Npierro@gramon.org

In-School Dental Screening Permission Form

The enclosed forms are due by Wednesday, November 20, 2019.

I give my permission for my child to participate in the KinderSmile Oral Health-In School Dental Services Program on Friday, December 2, 2109 at the Gramon School. I have read and completed the enclosed literature for the KinderSmile Dental Program and give my consent. Student Name:_______________________________________________ Date of Birth:__________________________ Class:________________ Address:____________________________________________________ Parent/Guardian Name:________________________________________ Parent Signature:_____________________________________________ Date:________________________________

KinderSmile Foundation Office: 973-744-7003 10 Broad Street Fax: 973-744-7008 Bloomfield, NJ 07003 www.KinderSmile.org KSF@KinderSmile.org FaceBook.com/KinderSmileFoundation

DENTRO DE LA ESCUELA FORMULARIO DENTAL Incluye visita de chequeo dental y 6 meses de visita

Complete all sections, sign and return to your child’s school. Questions? Please call (973) 744-7003

REVISE CADA ESTADO QUE SE APLICA A SU HIJO

Recientes Problemas Dentales Anemia de Células Falciformes

Alergia al Látex Anemia / Desmayo

Alergia a Medicamentos / Otro Epilepsia / Convulsiones

El Asma o Sibilancias Problemas de Hígado / Hepatitis

Problemas de Comportamiento Problemas Renales

Problemas del Corazón / Murmur VIH / SIDA

Cáncer Fiebre Reumática

Diabetes Tuberculosis

La Hemofilia / Problemas de Hemorragia Enfermedades Transmisibles

Nombre de Escuela o Programa __________________________________________ Condado ____________________________

Profesor ______________________________________________________________ Room _________Grade _________AM/PM

Nombre legal del niño_____________________________________ Fecha de nacimiento del niño ___________ Hombre / Mujer

Nombre del Padre / Guardián _______________________________________________________________________________

Dirección _____________________________________ Ciudad_____________________ Estado _______ Código Postal _______

Correo electrónico __________________________ Teléfono ( ) ________________ Teléfono Alt. ( ) _______________

HISTORIA MEDICA DEL NINO SI SU HIJO VE EL DENTISTA REGULARMENTE, POR FAVOR CONTINUE SERVICIOS CON QUE EL

PROVEEDOR.

INFORMACION DE SEGURO DENTAL Medicaid y NJ Family Care cubre el 100% del tratamiento

HISTORIA MEDICA DEL NINO

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NIÑO TIENE MEDICAID / NJ CUIDADO FAMILIAR □ United Health Care Community Plan (UHCCP) □ AmeriGroup □ Horizon NJ Health □ HealthPlex □ Straight Medicaid □ WellCare Health □ Aetna Better Health NJ Family Care Miembro ID Numero: ______________________________________

NIÑO TIENE SEGURO DENTAL PRIVADO

Nombre de la empresa (Aparte de Medicaid) ___________________________________ Teléfono________________

Grupo # ____________________ Empleador Nombre _______________________ Teléfono de Compañía__________

Nombre del Adulto Asegurado____________________________ Fecha de Nacimiento Adulto Asegurado __________

Miembro ID / Política #_________________________

Si el niño no está asegurado

Yo certifico que mi hijo no tiene seguro dental, solicito que la limpieza dental, examen y fluoruro se haga gratis. Ayuda no está disponible para trabajo de restauración Dental. Ayuda solo está disponible una vez por año escolar.

LEA Y FIRME ABAJO Solicita que el odontólogo realice el cuidado dental preventivo sobre mi hijo. He leído el AVISO IMPORTANTE Y CONSENTIMIENTO EN LA PARTE POSTERIOR DE ESTE FORMULARIO y entender y estar de acuerdo con estos términos.

_______________________________________________ ___________

Fecha __

Escriba el nombre _______________________________________________________________

Solicitar el consentimiento de fotos: Doy permiso para que mi hijo sea fotografiado

SOLO PARA USO ADMINISTRATIVO

IOE 6 mo

Exam, prophy, fluoride

Exam, prophy

4 bwx

PA films for diagnosis

Seal (M) molars (MB) molars & bicuspids

csf

Firme y Fecha aqui

2

4

3

Notifícanos los cambios de la historia clínica. Una historia médica y dental minuciosa y completa

es importante para un examen dental adecuada y evaluación.

Lista de Alergias ________________________________________________________

Nombre / Teléfono del médico del niño_____________________________________

Use el espacio siguiente para proporcionar detalles adicionales sobre la salud de su

hijo, incluyendo el tratamiento médico actual, otras enfermedades importantes y

medicamentos que está tomando. Añada otra página si es necesario.

______________________________________________________________ Fecha Aproximada de la última visita al

dentista. ________ CHECK SI ANTIBIÓTICOS PREMEDICACION SE REQUIERE

KinderSmile Foundation Office: 973-744-7003 10 Broad Street Fax: 973-744-7008 Bloomfield, NJ 07003 www.KinderSmile.org KSF@KinderSmile.org FaceBook.com/KinderSmileFoundation

DENTRO DE LA ESCUELA FORMULARIO DENTAL Incluye visita de chequeo dental y 6 meses de visita

Complete all sections, sign and return to your child’s school. Questions? Please call (973) 744-7003

Aviso importante y Consentimiento

Autorizo Fundación KinderSmile y sus dentistas afiliados para proporcionar los siguientes servicios no invasivos para el niño llamado así por los cuales yo soy el padre o tutor legal: examen dental e instrucciones de higiene bucal, limpieza dental, tratamiento de fluoruro, radiografías y selladores dentales.

Si bien es poco probable que su hijo podría ser dañado por el cuidado dental preventivo, en casos raros, los productos que utilizamos pueden causar reacciones alérgicas. Póngase en contacto con nosotros al (973) 744-7003 para obtener información adicional sobre los beneficios y riesgos de la atención odontológica preventiva.

Autorizo la Fundación KinderSmile como un proveedor de servicios dentales para facturar y cobrar el pago de Medicaid, el seguro de atención administrada, y otros pagadores. Entiendo perfectamente que al proporcionar mi firma, autorizo la Fundación KinderSmile para proporcionar servicios apropiados para mi hijo, y directamente la factura de mi hijo Medicaid / Managed Care, o compañías de seguros dentales privados para recibir el pago por los servicios prestados. A menos que yo he hecho arreglos previos para estar con mi hijo cuando se prestan los servicios, mi consentimiento firmado autoriza a mi hijo a ser servido sin mi presencia.

Es muy importante proveer toda la información solicitada sobre el historial médico / dental de su hijo, y su / su cobertura de seguro dental actual. La Fundación KinderSmile comprobará con el seguro de su hijo para verificar la elegibilidad para recibir servicios antes de nuestra visita a la escuela de su hijo. Si su hijo está cubierto por Medicaid o Managed Care (NJ Family Care), no se le cobrará por cualquier copago o la cantidad deducible.

Si su hijo está cubierto por un seguro dental privado, se le cobrará para cubrir el deducible aplicable, y co-pagos basado en su contrato de seguro. Si su hijo no tiene ningún tipo de seguro dental, por favor marque la casilla correspondiente en la Sección 2 del Formulario de Inscripción.

Las regulaciones de privacidad de HIPAA requieren que los proveedores de atención de salud y las organizaciones, así como a sus socios de negocios, desarrollar y seguir los procedimientos que garantizan la confidencialidad y seguridad de la información de salud protegida (PHI) cuando se transfiere, recibidas, manipulado o compartido. Esto se aplica a todas las formas de PHI, incluyendo papel, oral y electrónica, etc. Además, sólo la información de salud mínimo necesario para realizar negocios se va a utilizar o compartir.

Autorizo el intercambio de dicha información por este proveedor para cualquier pagador responsable y / o proveedor de servicios administrativos y sus subcontratistas para el uso y divulgación relacionada con el tratamiento de mi hijo, el pago de servicios y la coordinación de la asistencia sanitaria. He revisado las directrices de HIPAA como se indica anteriormente, y doy mi consentimiento para la divulgación de información de registro médico de mi hijo, incluyendo los registros obtenidos de proveedores.

Entiendo que toda la información compartida por los padres incluyendo los registros personales / médicos / dentales de los niños se mantendrá confidencial por la Fundación KinderSmile.

Este consentimiento firmado autoriza la visita de mi hijo inicial dental, se recomienda atención de seguimiento y 6 meses de visitas de chequeo revocatorio. Puedo retirar este consentimiento en cualquier momento por escrito a la siguiente dirección.

IN-SCHOOL DENTAL FORMIncludes Initial dental check-up & 6 month visit

Complete all sections, sign and return to your child’s school. Questions? Please call (973) 744-7003

KinderSmile Foundation Office: 973-744-700310 Broad Street, P.O. Box 1815 Fax: 973-744-7008Bloomfield, NJ 07003 www.KinderSmile.orgKSF@KinderSmile.org FaceBook.com/KinderSmileFoundation

Important notice & Consent

I authorize KinderSmile Foundation and its affiliated dentists to provide the following non-invasive services for the named child for whom I am the custodial parent or legal guardian: dental exam & oral hygiene instructions, teeth cleaning, fluoride treatment, x-rays & dental sealants.

School or Program Name ________________________________________________ County ____________________________Teacher ______________________________________________________________ Room _________Grade _________AM/PMChild’s Legal Name ____________________________________________ Child’s Date of Birth ________________ Male/FemaleParent/Guardian’s Name ____________________________________________________________________________________Address _______________________________________ City_________________________ State _______ Zip Code __________Email ____________________________________ Phone ( ) __________________ Alt. Phone ( ) __________________

TELL US ABOUTYOUR CHILD IF YOUR CHILD SEES A DENTIST REGULARLY, PLEASE CONTINUE SERVICES WITH THAT PROVIDER

INSURANCE INFORMATION Medicaid & NJ Family Care covers 100% of treatment

CHILD’S MEDICAL HISTORY

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CHILD HAS MEDICAID / NJ FAMILY CARE □ United Health Care Community Plan (UHCCP) □ AmeriGroup □ Horizon NJ Health □ HealthPlex□ Straight Medicaid □ WellCare Health □ Aetna Better Health

Child’s NJ Family Care ID Number: ______________________________________

CHILD HAS PRIVATE DENTAL INSURANCE COVERED BY THE EMPLOYER FOR PARENT/ GURADIANIns. Company Name (Other than Medicaid) ______________________Insurance Company Phone________________Group # __________Employer Name _______________________ Employer Company Phone________________Full Name of insured parent _________________________________ Birth Date of Insured Parent ______________Member ID/Policy # _________________________

CHILD IS UNINSURED I certify that my child does not have dental insurance, and request that dental cleaning, screening & Fluoride be provided free of charge. I understand that a further review will be done if my child needs follow-up care at the KinderSmile Community Oral Health Center and be considered to receive Charity Care

READ AND SIGN BELOW

I request that the dentist perform preventive dental care on my child. I have read the IMPORTANT NOTICE AND CONSENT ON THE BACK OF THIS FORM and understand and agree to these terms.

___________________________________________________ ________Date __

Print name __________________________________________________________

Please Check for Photo Consent: I give permission for my child to be photographed

OFFICE USE ONLYIOE 6 mo

Exam, prophy, fluorideExam, prophy4 bwxPA films for diagnosisSeal (M) molars (MB) molars & bicuspidscsf

Sign& Date Here

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CHECK EACH CONDITION THAT APPLIES TO YOUR CHILD

Recent Dental problems Sickle Cell AnemiaLatex Allergy Anemia/FaintingAllergy to Medications/Other Epilepsy/SeizuresAsthma or Wheezing Liver Problems/HepatitisBehavioral Problems Kidney ProblemsHeart Problems/Murmur HIV/AIDSRheumatic Fever CancerDiabetes TuberculosisHemophilia/Bleeding problems Communicable Diseases CHECK IF ANTIBIOTIC PRE-MEDICATION

REQUIRED

Notify us of any medical history changes. A thorough and complete medical and dental history is important for a proper dental examination and evaluation.List Allergies ___________________________________________________________Name/Phone # of child’s physician ________________________________________Use space below to provide additional details on your child’s health, including current medical treatment, other significant illnesses and list current medications. Attach another page as needed.______________________________________________________________

Aprox. Date of last dental visit. ______

4

3

IN-SCHOOL DENTAL FORMIncludes Initial dental check-up & 6 month visit

Complete all sections, sign and return to your child’s school. Questions? Please call (973) 744-7003

KinderSmile Foundation Office: 973-744-700310 Broad Street, P.O. Box 1815 Fax: 973-744-7008Bloomfield, NJ 07003 www.KinderSmile.orgKSF@KinderSmile.org FaceBook.com/KinderSmileFoundation

Important notice & Consent

While it is unlikely that your child could be harmed by preventative dental care, in rare cases, the products we use may cause allergic reactions. Please contact us at (973) 744-7003 for additional information regarding the benefits and risks of preventive dental care. Please complete all sections including your consent and leave this form with your child’s School Nurse. All our services at the initial visit for your child will be provided at your child’s School/ Childcare Program.

It is very important that you provide all the requested information regarding your child’s medical / dental history, and his/ her current dental insurance coverage. KinderSmile Foundation will check with your child’s insurance to verify the eligibility to receive services prior to our site visit to your child’s school. If your child is covered under Medicaid or Managed Care (NJ Family Care), you will not be billed for any co-payments or deductible amount.

If your child is covered under a private dental insurance by your Employer or Union, you will be billed to cover the applicable deductible, and co-payments based on your insurance contract. However a waiver to pay the applicable balanced will be considered on an individual basis.

If your child does not have any dental insurance, please check the appropriate box under Section 2 of the Registration Form, and we need to further verify with you for your child to qualify to receive dental care free of charges Please include your complete contact information for us to further communicate with you.

The HIPAA Privacy regulations require health care providers and organizations, as well as their business associates, develop and follow procedures that ensure the confidentiality and security of protected health information (PHI) when it is transferred, received, handled, or shared. This applies to all forms of PHI, including paper, oral, and electronic, etc. Furthermore, only the minimum health information necessary to conduct business is to be used or shared. We appreciate you giving your consent to take pictures of your child practicing good oral hygiene and feeling good about going the dentist. Pictures of your child, individual and part of a group included in our newsletter will encourage other children and parents about going to the dentist and having a great check-up.

Attention Parents/ Guardians: Please review all the information, and provide your consent as stated below.

I authorize & direct KinderSmile Foundation as a provider of dental services to bill & collect payment from Medicaid, Managed Care insurance, or other payers. I fully understand that by providing my signature, I authorize KinderSmile Foundation to provide appropriate services to my child, and directly bill my child’s Medicaid/ Managed Care, or private dental insurance carriers to get paid for services provided. Unless I have made previous arrangements to be with my child when the services are rendered, my signed consent authorizes my child to be served without my presence

I authorize release of such information by this provider to any responsible payer and/or administrative service provider, and their subcontractors for use and disclosure relating to my child’s treatment, payment for services and coordination of health care. I have reviewed the HIPAA Guidelines as listed above, and provide my consent to the release of my child’s medical record information, including records obtained from other the providers. I understand that all information shared by the parent including the personal/ medical / dental records of the children will be kept confidential by KinderSmile Foundation.

This signed consent authorizes my child’s initial dental visit, recommended follow-up care & 6-month recall checkup visits. I may withdraw this consent at any time in writing to the address below.

KinderSmile Foundation is a nonprofit 501(c)(3) corporation. Our dental home, KinderSmile Community OralHealth Center, is made possible in part by grants from Partners for Health Foundation, The HealthcareFoundation of NJ, Horizon Foundation for NJ, Delta Dental of NJ Foundation, The Montclair Foundation,Investors Bank and BCB Community Bank, among other generous supporters. ksf@kindersmile.org

According to the American DentalAssociation, children should receive anoral exam & teeth cleaning at leasttwice per year, starting at age one.

Tues/Thur 12pm - 7pm

10 Broad Street, Bloomfield, NJ 07003 973-744-7003

Serving pregnant women, babies, and children 0-17 years of ageMedicaid and NJ FamilyCare acceptedUninsured patients welcomeEasily accessible by car, bus or train todowntown Bloomfield Avenue

We provide optimal oral health care,regardless of a family's ability to pay.

Monday 9am - 6pm

Wednesday 12pm - 6pm

Friday (alternating) 9am - 2pm

Saturday (alternating) 9am - 2pm

Has your child visited the dentist inthe last 6 months?

Learn more at www.kindersmile.org/dental-home.

KinderSmile Foundation es una organización benéfica 501(c)(3). Nuestro hogar dental, KinderSmile CommunityOral Health Center, es posible en parte por subvenciones de Partners for Health Foundation, The HealthcareFoundation of NJ, Horizon Foundation for NJ, Delta Dental of NJ Foundation, The Montclair Foundation,Investors Bank and BCB Community Bank, entre otros partidarios generosos. ksf@kindersmile.org

Según la Asociación Dental Americana,los niños deben recibir un examen oral ylimpieza dental al menos dos veces alaño, comenzando a la edad de uno.

10 Broad Street, Bloomfield, NJ 07003 973-744-7003

Sirviendo a mujeres embarazadas,bebés, y niños de 0-17 años de edadMedicaid y NJ FamilyCare son aceptadosPacientes sin seguro bienvenidosDe fácil acceso en coche, autobús o trenal centro de Bloomfield Avenue

Brindamos una atención médica oralóptima, independientemente de lacapacidad de pago de una familia.

Sábado (alterno)

9am - 2pm

¿Ha visitado su hijo al dentista en losúltimos 6 meses?

Obtenga más información en www.kindersmile.org/dental-home.

mar/jue 12pm - 7pm

lunes 9am - 6pm

miércoles 12pm - 6pm

viernes (alterno)

9am - 2pm

sábado (alterno)

9am - 2pm