Critical Dental Assistance Program

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

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Address

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 set forth by Wounded Veterans Relief Fund. The mission of the Critical Dental Assistance Program is to provide critical dental care to wounded and disabled Florida veterans who are at least 30% VA service-connected and do not otherwise qualify for dental coverage through the Veterans Administration. All veterans must first be approved by Wounded Veterans Relief Fund herein referred to as “WVRF”.

Fee

We have created our own internal fee schedule for dental clinics to adopt. In order for us to support more disabled Florida veterans, we would appreciate any additional discounts on services rendered.

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

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.

Dental Providers

Please list ALL participating dental providers and their dental specialties.

Dental Services

Please list ALL dental services offered at this dental practice.

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

Lab Partners

Scan the QR code on the right to review a complete list of dental labs we partner with.

wounded-veterans-relief-fund-CDAP-QR-lab-partners-1

If you do not partner with one or more of the dental labs listed above and wish to discuss a potential partnership, please state the name of the lab(s) below.

Please also provide the names of labs and their representatives whom your office already works with. We are still expanding our network and may be able to establish an additional partnership with your assistance.

Implant Companies

Scan the QR code on the right to review a complete list of implant companies we partner with.

wounded-veterans-relief-fund-CDAP-QR-implant-companies-1

If you do not partner with one or more of the implant companies listed above and wish to discuss a potential partnership, please state the name of the company below.

Please also provide the names of implant companies and their representatives whom your office already works with. We are still expanding our network and may be able to establish an additional partnership with your assistance.

Please provide the name of the dental software program your office uses to generate dental treatment plans.

Does the staff member responsible for creating dental treatment plans need assistance with adding our agreed upon fee schedule into the above named software system? Please confirm with this staff member before answering.(Required)

Additional Costs

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

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.

• 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.

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

Terms of Payment(Required)

If Direct Deposit was selected above, please add Account Info

Media Release

WVRF requires before and after photos of the veterans’ smile with teeth showing. The expectation is to receive a before photo along with the proposed treatment plan following the veterans’ initial exam. On the day of the veterans’ final appointment, we ask that an after photo be taken and emailed to our Dental Program Manager, Jade Sembric. Veterans will be required to sign a media release form upon entering the program as part of the application process. All media will be used to highlight your support to our veterans. Please check the box of the media outlets you allow WVRF to share your photos with.

Media Release checkboxes

Point of Contact

All correspondence, treatment plans, X-rays, PANOs, chart notes, invoices, and photos are to be sent to our Dental Program Manager via email.

Jade Sembric

Wounded Veterans Relief Fund

Dental Program Manager

Email: JSembric@wvrf.org

Main: 561.855.4207 ext. 408

Direct: 561.408.0045

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.

ACKNOWLEDGED AND AGREED:

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