Wake Smiles        

(Eligibility) Enrollment Application   

Raleigh/Wake County Dental Society

Note: Wake Smiles Is For Wake County Residents Only

Last Name____________________________  First Name_________________________  

Street Address__________________________________     Apt. #__________

City/Zip___________________________________  COUNTY:   WAKE     

Mailing Address ( If Different)_____________________________________________

City/Zip_____________________________

If under 18: Mother's Name_____________________  Father's Name__________________

Home Phone# _______________Work Phone#_________________

Date of Birth_______________ Gender_______________

Social Security # _______________________________

Emergency Contact: _______________________

Relationship to Patient_____________________

Phone___________________

PREVIOUSLY ENROLLED?    Yes       No

(If patient is under 18, information below is completed for head of household.)

Marital Status: Married Separated Divorced Single Widowed

Do you have children under the age of 18? Yes    No   If yes, how many? ________

Do you have children 18-21 in school f/t? Yes    No   If yes, how many?   ________

Are you a student and under age 21? Yes    No If yes, include parent's income with your own in the income section below. Include total number of people in parent's household where indicated below.

INSURANCE INFORMATION

Have you previously been enrolled in Project Access or Wake Smiles? Yes No If so, when? _______________________________________________

Do you currently have Medicare/Medicaid? Yes No Application Pending

Do you currently have health insurance? Yes No

Have you ever received health insurance or any medical benefits, including Medicaid?    Yes No

Is there a possibility you will receive Medicare, Medicaid or Health Insurance?    Yes No

If yes, explain:_______________________________________________________

OTHER BENEFITS

Are you on Work First Program?    Yes    No

Do you have a military related disability and did you serve for at least 3 years?    Yes    No

Do you receive Social Security disability or SSI disability?    Yes    No

If so, which?   

Do you currently receive assistance from any State Programs?    Yes    No

If yes, which?     

Have you been seen by any health care provider in the last 12 months, including the ER, Health Dept., WakeMed Faculty Physicians, Urgent Care, or a private doctor's office? Yes No If yes, where?     

EMPLOYMENT (INCOME)

Your employer: _____________________________ Phone:____________________

Number of people in your household:      Your annual gross income:   $ ________

Total annual gross income of other members of household:     $ ________

     Total Household Income:    $ _________

Proof of Income:

( ) W-2   ( ) Last 2 pay stubs ( ) Last year's tax return   ( ) Letter from employer
Other ______________________________________

Enrollment Site: _______________________________

Date: ____________________Phone # of Enrollment Site_______________________

Contact:________________________     Date of last eligibility update_______________

Person Completing Application:_________________________________

Referring Physician/Agency:_____________________________________

Referred To: ____________________________________________________________

                    Specialty              Practice             Dentist                      Phone

Appointment Date___________________   Appointment Time__________________

(Do not fax without referral appointment and all patient information complete)

Fax:   (919) 341-3826.

Faxes are ONLY accepted from REFERRING PROGRAMS and

NOT individuals!