Report Your Charitable Dental Care

Dentists are called upon, on a regular basis, to provide charitable dental care within their community. It has become very clear that North Carolina legislators are interested in the charitable care given by dentists, especially through the Missions of Mercy Clinics, Give Kids a Smile Program and Donated Dental Services. Even with these organized programs, the tracking of charitable dental care, provided by dentists, remains difficult.

After you have completed any charitable dental care, please complete and mail, fax, or e-mail this form to the North Carolina Dental Society. This will assist the NCDS with its lobbying efforts and help to insure that North Carolina dentists are recognized for doing their part in addressing the oral health needs of those unable to pay for services. Do not report the value of any services that are already being reported to the Donated Dental Services program, as those will already be recorded. Feel free to report the amount of a charitable discount given as well, even if the patient did pay for part of the services. Your participation will be beneficial towards further enhancing our image as a profession, and is greatly appreciated.

Please, do not use this form to report care provided for Medicaid, Medicare, or Donated Dental Service patients.

Required field(s) are indicated by an *.
* Date of Event / / (MM/DD/YYYY)
report number of patients for an Open Door Clinic
state NA or None if not available