Smile Check — Adults

You might know that having good oral health can help prevent bad breath, cavities, and gum disease — but did you know it can impact your risk for heart attack, stroke, diabetes, and other chronic conditions?

The Smile Check Program is available to adults ages 19 and older who enrolled in Medicaid. The program will provide you with resources and empower you to take control of your oral health and improve overall health.

The program offers dental screenings, fluoride varnish application when needed and available, case management, and oral health education by a registered dental hygienist. Patients have no out-of-pocket costs for this service.

Your participation will invite a dental health coordinator to contact you to discuss your oral health concerns and resources for treatment, as well as provide personal oral health counseling.

To participate, you must complete all the information and questions below.

Smile Check 5 - Adults

(mm/dd/yyyy)
Race (check any that apply) *
This is a federal requirement.
Language
Dental Insurance *
What is the best way to contact you? (Check all that apply.) *

Adult Oral Health Screening

What best describes you? *
Do you use any of the following? Check all that apply.
When do you normally brush your teeth? Check all that apply. *
How often do you floss your teeth? *
How often during the past 12 months did you have a toothache or feel discomfort due to your teeth? *
Are you currently pregnant?
How often did you go to the dentist during the past 12 months? *
What was the reason for your last visit to the dentist? Check all that apply.
Have you ever done/had any of the following? Check all that apply.
Have you missed any work in the last 12 months due to dental problems or pain? *
Medical conditions can affect oral health and your ability to maintain your oral health. Do you have any of the following? Check all that apply.
Have you ever had any of the following? Check all that apply.
What oral health information would you find helpful?
What type of water do you drink?
Are you currently having any of the following problems? Check all that apply.
Have you gone to the emergency room for tooth or mouth pain or infection in the last 12 months? Skip the next two questions if you answer no. *
If yes, how many times?
What treatment did they provide to resolve the problem? Check all that apply.
What type of problems would prevent you from going to the dentist? Check all that apply.

CONSENT FOR EXAMS-TESTS-TREATMENT-SERVICES-RELEASE OF HEALTH AND INSURANCE INFORMATION

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY
This consent indicates that you or your child may be examined, have appropriate tests, receive treatments and/or minor procedures, receive referrals, and/or receive any other services by a person authorized by the Division of Public Health (DPH). You have reviewed the DPH policy on chaperones and discussed it with your child.
You certify that you are

CONSENT TO PARTICIPATE IN HEALTH INFORMATION EXCHANGE

Receipt of Notice of Patient Privacy Practices (Acknowledgment)

By submitting this agreement, you acknowledge the Notice of Patient Privacy Practices.

Health Information Exchange
Delaware’s Health Information Exchange Network (DHIN) allows health care providers to share health care information about patients electronically for several purposes, such as treatment, quality assurance, and state law reporting requirements. Understand that if you go to a Delaware Health and Social Services (DHSS) or Division of Public Health (DPH) facility, staff may get a copy of health care information electronically through DHIN's connections with other health care providers.

By submitting this consent, you agree to the use and release of all health care information for treatment, payment, and health care operations among the affiliated entities of Delaware Health and Social Services, Notice of Patient Privacy Practices, as amended from time to time.

Assignment of Benefits and Medical Records Release to Delaware Health and Social Services, Division of Public Health

Submitting this consent gives authorization for the following: Any insurance benefits are to be paid directly to DHSS; the release of pertinent medical information to insurance carriers; the responsibility to pay for non-covered services; to release and hold harmless the State of Delaware, DHSS, DPH, and its agents and/or staff from any liability for any injuries suffered as a result of any exams, test, treatment, and/or services rendered; the consent to taking samples, cultures, or lab tests that are deemed necessary; the chance to correct and change information to make sure it is correct and complete; to know what information is being disclosed.

I have read this form and/or if requested, had it read to me. Any disclosure of my Protected Health Information (PHI) carries with it the potential for disclosure by the recipient, and the PHI may not be protected by the federal privacy rules.

This consent shall apply to all Division of Public Health services for a period of one year from the date of submission and can be revoked, in writing, at any time. Please note, receiving family planning services is not a prerequisite for receiving any other services offered by DPH.

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