Response

Maine Bureau of Veterans' Services -
Veteran's Dental Network Service Request Form

Date Submitted

Veteran's Contact Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Home Phone

Work Phone

Cell Phone

You must meet the following criteria to qualify for the MVDN. Answer the following six questions:

I am a Maine resident.

County

I am not 100% service-connected to the VA (meaning you don't already receive dental care through Togus or the Bangor or Portland Community Based Outpatient Clinics).

I do not have dental insurance and cannot afford to purchase it.

I do not have MaineCare Adult Dental Insurance Coverage

I cannot afford to pay for my dental care out of pocket.

My DD Form 214 shows an Honorable or General Under Honorable conditions discharge

For National Guard/Reservists only - I served on active duty (other than for training)

The Maine Veterans' Dental Network grant funding covers the following services:

Preventative, diagnostic, restorative, oral surgery, and major restorative dental care.

Services not provided under the grant include: Dental implants, orthodontics, fixed bridges, telehealth, and PPE charges.

Required Documents to Participate in the Maine Veterans' Dental Network

1. Copy of your DD Form 214 military discharge papers

2. Copy of Maine Drivers License or Identification Card

Year Applying

DOB

Gender

SSN#

Maine Driver License Or State Identification Number

Branch of Service

War Period

Rank

Character of Service

Did you serve under another name?

If yes, please enter that full name

Middle Name

Last Name

Entered Active Duty

Released Active Duty

Are you connected to the VA?

What are your dental concerns?

Please attach your DD Form 214

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RequiredPlease attach your State of Maine Driver License or State Identification

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Are you interested in learning about other veterans' benefits from the Maine Bureau of Veterans' Services? If so, please check the appropriate service request below:

Patient Code of Conduct

I agree to abide by the Maine Veterans' Dental Network (MVDN) Patient Code of Conduct and understand that if I do not follow them, I will be asked to leave the program, will lose my grant funding for oral healthcare, and will be restricted from future participation in the MVDN. By signing this document below, I agree to abide by the following guidelines:

Everyone will be treated with kindness, dignity, and respect. Offensive comments about race, religion, gender, sexual orientation, or personal traits are not acceptable, and neither is the refusal to see a clinician or associate based on these traits.

All patients and visitors will use respectful, appropriate language and behavior. Physical or verbal threats or assaults, suggestive or explicit words, phrases, gestures, or actions will not be tolerated.

All patients and visitors will respect patient privacy and avoid disrupting other patients' care or experiences.

By electronically signing this document, I attest that the above statements are true, and I agree to abide by the Patient Code of Conduct. If my statements are found not to be true, I accept the full financial responsibility for my dental treatment, and if I don't follow the Patient Code of Conduct, I understand that I will be terminated from this grant funded oral healthcare program. Additionally, I give my permission for my name, address, and phone number to be shared for the purpose of establishing me with the dental clinic I am assigned to. I acknowledge

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