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Pro Bono Dental Care Reporting Form

*Your Name:
  *Required fields
*Address:
*City:
*State:
*Zip Code:
*Phone (work):
Fax:
*E-mail Address:
Dates of Service:
Please indicate the number of patients seen in each of the following age groups:
0 to 6 years 7 to 17 years 18 to 64 years 65 years and older
Please indicate how many of these patients had special needs or were handicapped
Please indicate the number and type of procedures performed:

*Total value of services provided: Your specialty, if applicable:

If applicable, please indicate the number of Medical Assistance patients for whom you provided free dental serices without submitting clainms to the Department of Public Welfare during the last 12 months:

If you see MA or CHIP patients, what dollar amount in participating adjustments do you incur each fiscal year?
Would you consider volunteering if called upon to check: Nursing home patients Special needs patients
Check this box if you wish to remain anonymous when data are shared with elected officials:

 
 
 
 
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