Dental Provider Forms and Compliance

Treatment Plan Template – Example | Here is a treatment plan template. You could create something similar to use with your patients. The form asks that both patient and dentist sign the form.

Periodontal Treatment Pledge and Action Plan | Here is the treatment plan you must have your patients sign before they begin periodontal treatment. (Also available in SpanishFrench, and Portuguese).

Informed Consent for Payment – Sample | Example of the information needed for an informed consent form for Dental Procedures Not Covered by the Connecticut Dental Health Partnership (the Dental Plan for HUSKY Health)

Client Acknowledgment of the Receipt of Dentures | This form is for both the provider and patient to fill out before a patient receives their dentures.

Third Party Liability (TPL) Information (How to Update) | Important information and fax/phone numbers to use when reporting changes to a client’s third-party insurance information.

Annual Provider Survey

Secure Access to Dental Plan Related Patient Information

Letter To HUSKY Health Dental Provider | As a provider partner with the Connecticut Dental Health Partnership (CTDHP) – the dental plan for HUSKY Health – we appreciate your continued participation and support of the partnership. Because of our work together, Connecticut’s Medicaid dental program is seen as one of, if not the, best in the country.

Language Assistance Services For Individuals With Limited English Proficiency | Providers will take reasonable steps to provide free-of-charge language assistance services to people who speak languages we are likely to hear in our practice and who don’t speak English well enough to talk to us about the dental care we are providing.

Compliance Required – Connecticut Dentists | Section 1557 is the civil rights provision of the Federal Affordable Care Act (ACA) of 2010. Section 1557 prohibits discrimination on the grounds of race, color, national origin, sex, age or disability in certain health programs and activities. New rules under Section 1557 change how dentists interact with patients who are deaf and hard of hearing (DHOH) and patients with limited English proficiency (LEP), which means they are not fluent in English.

Notice Of Non-Discrimination (15 Employees Or Less) | Discrimination is Against the Law – Our Dental Practice complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Our Dental Practice does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Notice Of Non-Discrimination (More Than 15 Employees) | Discrimination is Against the Law – [Name of covered entity] complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. [Name of covered entity] does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.