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2. Name of Dental Practice
3. Phone number
5. Website
6. Email
8. Specialty (if applicable)
9. Is this a mobile dental service?

   1. Yes
   2. No
10. Do you offer appointments, walk-in services, or both?

    1. Appointments
    2. Walk-ins
    3. Both
12. Address
13. City
15. State
16. Zip Code
18. Do you accept Medicaid, Apple Health, Provider One insurance options

    1. Yes
    2. No
19. Do you offer reduced fees or a sliding fee scale?

    1. Yes
    2. Yes, for services not covered by insurance
    3. Yes, for children
    4. No
21. Are you ABCD (Access to Baby and Child Dentistry) certified?

    1. Yes. We have dentists who have completed ABCD training and are certified to receive enhanced Medicaid reimbursement rates for children under 6 years old on Medicaid/Apple Health
    2. No. We have dental professionals who received the ABCD training, but did not complete the certification process
    3. No. None of our dental professionals are ABCD trained or certified
22. Would you like more information on ABCD trainings?

    1. Yes
    2. No
23. Please provide your email and/or phone number:
25. Please list all languages spoken at your practice
26. Are interpretation services available for patients who speak other languages?

    1. Yes, in person
    2. Yes, by phone
    3. Yes, if arranged in advance
    4. No
28. Does you practice provide emergency care?

    1. Yes
    2. Yes, with limitations
    3. No
29. Please specify any limitations for emergency care (extraction only, children only, etc.)
31. Which of the following demographics do you serve? (Check all that apply)

    1. Infants (0-1)
    2. Young Children (1-5)
    3. Children and Teens (6-20)
    4. Pregnant Women
    5. Adults (20+)
    6. Adults with a developmental disability
    7. Military (TriCare)
    8. Seniors (65+)
    9. Tribal members
32. Additional information
    Please include other important information potential patients should know about your practice, particularly low-income patients.
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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

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