APPLICATIONS

 

Application for Dental/Medical Services




Photo ID (Required)
JPG, PNG or PDF
Up to 1Mb

Recent Headshot (Required)
JPG, PNG or PDF
Up to 2Mb

1040 pages 1-2 (Required)
JPG, PNG or PDF
Up to 2Mb

Latest Pay Stubs (Required if 18-64 years old)
JPG, PNG or PDF
Up to 2Mb

Social Security/Disability Awards Letter (Required if 65+ years old and applying for Dental Services)
JPG, PNG or PDF
Up to 2Mb


If you answered "No" to the question above, then you are not eligible to apply or renew online. Please call the clinic at (903) 596-9471 to make an appointment with the Admissions Department.


Dental Applicants Only

Conditions and Guidelines for Dental Patients

  • I understand that fees for Dental services are separate from my initial visit fee.
  • I understand that Dental pricing may vary based on the services that I receive.
  • I understand that a 50% deposit is required at the time of scheduling my appointment.
  • I understand that there will be no refund of deposits towards my Dental appointment.
  • I understand that if I need to cancel an appointment, then I will call 24 hours ahead of time or sooner so that Bethesda may give that appointment time to someone else.
  • I understand that if I cancel an appointment on the same day as that appointment, or if I miss an appointment and do not call ahead, I will forfeit $20.00 from my pre-pay for that appointment.
  • I understand that I will be dismissed from Bethesda Dental Clinic if I miss my initial appointment or cancel any three appointments.
  • I understand that if I am over 10 minutes late, I will not be seen.

All Applicants

By clicking the Submit button below, I hereby declare that the above information is true and correct. I know that any false information could jeopardize my eligibility to receive medical attention at Bethesda Health Clinic.

HOW TO APPLY

STEP 1
Meet Patient Eligibility Requirements

  • Low income adult (age 18-64)
  • Dental-only applicants can be 65+
  • Employed or perform an important unpaid job, such as being a caregiver, volunteer or participant in a self-improvement program (e.g. education, rehabilitation, etc.)
  • Uninsured or underinsured
STEP 2
Prepare Your Documentation

Scan or photograph the following documents and save them as JPG, PNG or PDF files. (Each file must be 2Mb or less in size.)

  • A current government-issued photo ID
  • A recent headshot
  • Your most recent paystubs
  • Pages 1 and 2 of your latest filed tax return (form 1040)
  • If 65+ and applying for Dental-only, your Social Security/Disability Awards letter
STEP 3

Complete and Submit All 4 Online Forms

  • Application for Medical/Dental Services
  • Medical History
  • Waiver of Liability
  • Self-Sufficiency Matrix
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