Become a WVRF Dental Partner

Letter of Acknowledgment Between the Wounded Veterans Relief Fund and CDAP Providers.

Download the Wounded Veterans Relief Fund CDAP Fee Schedule.

Date(Required)

Name of Practice(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

RE: Wounded Veterans Relief Fund Critical Dental Assistance Program

The purpose of this Letter of Acknowledgment is for the Dental Partner to acknowledge and agree to the dental assistance program process and expectations established by Wounded Veterans Relief Fund (“WVRF”). WVRF’s Critical Dental Assistance Program (CDAP) provides critical dental care to Florida veterans in need, including veterans who do not qualify for dental coverage through the U.S. Department of Veterans Affairs. All veterans must first be reviewed and approved by WVRF prior to receiving assistance through the program.

Fee

WVRF utilizes two approved fee schedules for services provided through the Critical Dental Assistance Program (CDAP): an internal WVRF fee schedule and the Florida Veterans Foundation (FVF) Grant fee schedule. Applicable reimbursement rates are determined based on the funding source associated with each approved veteran case.

Click here to view fee schedules

Please select the fee schedule option you will be using:(Required)

WVRF Fee Schedule Only

WVRF Fee Schedule with Additional Discount

Grant Fee Schedule

Pro Bono

If you wish to include an additional discount, please state the discount you wish to apply toward the services rendered. Be as specific as possible. For example, if you only wish to provide a discount to certain services, please provide the associated CDT codes and the discount percentage. In addition, if you wish to provide pro bono services, please clearly state which services will be free and which services will be charged to WVRF. If you do not wish to provide an additional discount, please state that in the lines provided below.

Additional Discounts

Dental Providers

Please list ALL participating dental providers and their dental specialties.

Dental Providers and Specialities

Dental Services

Please list ALL dental services offered at this dental practice.

Dental Services

If your office provides denture services, please list the type of dentures provided.

Type of Dentures Provided

Lab and Implant Companies

Please list the lab and implant companies your office currently uses for treatment.

Lab and Implant Companies

Additional Costs

WVRF does not provide assistance with cosmetic dentistry, routine maintenance, or follow-up care beyond the agreed upon treatment plan. Any additional services requested by the veteran outside of the approved treatment will become their responsibility.

Additional Costs Initial Here(Required)

Timeline

• The Dental Partner will meet with the qualified veteran within 14 days of the referral from WVRF due to the urgent, critical need for dental care.

• Follow up care will be scheduled as deemed necessary and in a timely manner.

• Dental Partners are required to submit one veteran headshot “before” photo at the start of treatment and one headshot “after” photo upon completion of treatment to demonstrate the impact of care provided through CDAP.

• WVRF requires dental partners to provide progress updates regarding upcoming appointment dates/times, treatment plan status, missed appointments, walk-out statements, and any questions or concerns you may have about the process and/or the veteran.

Timeline Initial Here(Required)

Terms of Payment

If your office charges credit card fees, please choose an alternate payment method.(Required)

Credit Card Authorization sent via email to the designated individual

Credit Card payment made over the phone with the designated individual

Secure Link emailed directly from the dental clinic (if applicable)

Direct Deposit

Account Name(Required)

Routing Number(Required)

Account Number(Required)

Media Release

Dental Partners are required to submit one veteran headshot “before” photo at the start of treatment and one headshot “after” photo upon completion of treatment to demonstrate the impact of care provided through CDAP. Please forward all photo’s to WVRF representative. Veterans are required to sign a media release form upon entering WVRF’s dental program. All media will be used to highlight your support to our veterans.

Media Release Initial Here(Required)

Point of Contact

All correspondence, treatment plans, x rays, PANOs, chart notes, invoices, photos, and related documentation must be submitted directly to the WVRF staff member who initiated and is coordinating the veteran’s dental care.

Tami Martin

Wounded Veterans Relief Fund

Director of Veterans Dental Program

Email: dental@wvrf.org

Main: 561.855.4207 ext. 422

Direct: 561.408.5576

Please provide contact information for the main Point of Contact (POC) who we will be sending new veteran referrals to, discussing treatment plan options with, and making payments to. If multiple, please provide ALL. Please ensure this POC is informed of who we are, our agreement, and that they have been made the POC to avoid confusion. If current named POC leaves for any reason, please update WVRF with the new POCs name and contact information.

Name of POC(Required)

Title of POC(Required)

Email of POC(Required)

Phone of POC(Required)

Dentist Direct Phone(Required)

Dentist Direct Email(Required)

Questions?

AFor all other questions or concerns please reach out to Tami Martin, EFDA, Director of Veterans Dental Program dental@wvrf.org 561-408-5576

ACKNOWLEDGED AND AGREED:

Name of Practice(Required)

Name of Representative(Required)

Title of Representative(Required)

Date(Required)

Signature(Required)