MICHIGAN DENTAL PROGRAM ANNUAL APPLICATION
Michigan Department of Health and Human Services
New Member
Annual Renewal
DEMOGRAPHICS
Name
Date of Birth	SSN	Phone
Current Address	APT #
City	State	Zip Code	County
Permanent Homeless
RACE AND ETHNICITY
Gender: Female Male Transgender Unknown
Transgender M to F Transgender F to M Refuse to report
Race	Ethnicity
Black or African American	Pacific Islander/Hawaiian	Hispanic/Latino
Asian	Native American	Non-Hispanic
Caucasian	Other Unknown	Unknown
INCOME / OTHER COVERAGE ELIGIBILITY
Household Size (including self, spouse, and/or dependents living with you)	Total Gross Annual Income (attach most recent proof of income)
$
Do you have Medicare?
Part A/B	Part D	No
Do you have private insurance?
Yes	No
Have you applied for Medicaid?
Yes	No
Do you have Healthy Michigan Plan?
Yes Name of Plan _________________________	No
Do you have private dental insurance?
Yes	No
No Insurance	Other Public: ___________________
All Members - HIV STATUS (please complete)
HIV diagnosed on (date)	AIDS diagnosed on (date)
HIV positive (Not AIDS)	CDC Defined AIDS
NEW MEMBERS ONLY - HIV STATUS attach labs within the last 6 months and show viral load and/or positive status from an eligible laboratory test.
Absolute CD4 Numbers/MM3	Test Date	Primary Caregiver
______ ______	____________
HIV RNA Viral Loads	Test Date
______ ______	____________

AUTHORIZATION FOR RELEASE OF INFORMATION
I understand that if I become enrolled in a dental insurance program that pays for any portion of my dental or if I qualify for medical assistance through other federal, state or county medical benefit programs, I must immediately notify the Michigan Department of Health and Human Services, Michigan Dental Program (MDP) in addition to my dentist. I authorize the MDP to receive, disclose, and discuss dental information related to the care and treatment of my HIV infection with any health insurance or government health insurance program representative, or other individuals as required and necessary. In addition, specific agencies and phone numbers are listed below. I understand it is my responsibility to recertify every six-months with MDP. I understand that if I submit an application that is determined to be incomplete in fulfilling the requirements for approval that my assistance will be inactive until all the requirements are met. I understand that if any of the information provided on this application changes that I must notify the MDP immediately. The information that I have provided on this application is complete and true to the best of my knowledge. I certify that I meet the eligibility requirements as specified in the instructions and have followed the necessary steps that are required for me to be on the Michigan Dental Program. In addition, I understand that failure to report changes and/or reporting of inaccurate information may affect MDP coverage and program eligibility. This application, when completed, contains patient information that must be protected in accordance with the Health Insurance Portability and Accountability Act.
Case Manager or Personal Representative (optional)
Signature of Applicant
Name of Applicant (print)
Please mail or fax application and any supporting documentation to:
Michigan Dental Program
109 Michigan Avenue, 5th Floor
Lansing, Michigan 48913
Phone: 844-648-3384
Fax: 517-763-0220
Please allow 10 business days for processing non-emergency cases.
MDP office use only
Medicaid Healthy Michigan Plan
Michigan Resident
Income
Labs (proof of status)
Date ____________________ Initials ____________ Subgroup ____________________
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
Authority: PA 368 of 1978 Completion: Is voluntary, but is necessary to receive coverage under Michigan Dental Program.