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.

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

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

For National Guard 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. A copy of your DD-214 military discharge papers.

DD-214 submitted with your application?

If not, would you like MBVS to research

Year Applying

DOB

Gender

SSN#

ME Driver License #

State of Maine ID

What branch of the service and years did you serve in the U.S. Miltiary?

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?

VA Disability Rating %

Would you like to meet with a Veterans Services Officer?

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:

State Park Pass

Honorable Service Certificate

I would like to meet with a Veterans' Services Officer

Cemetery Services

VA Services

I would like an overview of state benefits

I am unable to attached a copy of my Maine driver's license and DD Form 214 (discharge papers - Honorable or General Under Honorable conditions only), and will mail a photocopy to: Maine Bureau of Veterans' Services, C/O Dental Program, 117 State House Station, Augusta, ME 04333-0117

Yes

Please attach your DD-214

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By electronically signing this document, I attest that the above statements are true. If they are found not to be, I accept the full financial responsibility for my dental treatment.

I acknowledge

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