REGISTER AN ORGANIZATION INTERESTED IN OFFERING FREE OR
REDUCED DENTAL ASSESSMENTS FOR CHILDREN IN NEW YORK STATE
This form will allow you to submit the contact information for either yourself and/or an
organization interested in providing free or reduced fee dental assessments for children who
would otherwise be unable to afford such. Please note that this information will be held in the
strictest confidence, but that by submitting this information, you are authorizing us to share
such information with the New York State Department of Health and the New York State
Department of Education, so as to allow them to contact interested individuals and
organizations to obtain additional necessary information. Thank you for being a part of this
important endeavor.
Organization's name*:
Organization's  e-mail address*:
Organization's address*:
Organization's city, state, and zip*:
Organization's phone number *:
Does the organization/clinic
accept Medicaid?*
Yes, the organization does accept Medicaid
No, the organization DOES NOT accept Medicaid
Additional comments
and/or questions:
SUBMITTING INDIVIDUAL DISCLAIMER:
I certify that I am submitting this information to the best of my knowledge and know that this
information will be shared in the strictest confidence with the New York State Department of
Health and New York State Department of Education respectively so as to contact the above
mentioned organization so as to agree to their willingness to be placed on a list of organization
and dentists willing to offer free or reduced fee dental assessments for children who would
otherwise not have access to dental care, so that they may fulfill the request for a dental health
certificate.
Yes, I have read and agree to the above stated disclaimer in it's entirety and
grant the New York State Dental Foundation the right to share the above
information with the New York State Department of Health and/or New York
State Department of Education.
YOUR name (electronic signature):
The New York State Dental Foundation's public advocacy program for dental health certificates has been made possible by a grant from
The American Dental Association.
20 Corporate Woods Blvd., Suite 602
Albany, New York 12211
ph: 518-465-0044
fax: 518-465-3219
alt: 800-255-2100
nysdf@nysdental.org
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