Public Health Dental Program Patient Eligibility Application Form
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1
2Vancouver Community Public Health Dental Program
Robert and Lily Lee Family Community Health Centre
#210 – 1669 East Broadway, Vancouver, BC V5N 1V9
Telephone: 604-675-3981 Facsimile: 604-872-0108
PUBLIC HEALTH DENTAL PROGRAM
New Application
Renewal
PATIENT ELIGIBILITY APPLICATION FORM
PART I – ELIGIBILITY CRITERIA
To be eligible you must:
•
Reside in Vancouver.
•
Have dependent child(ren) Grade 7 or under.
•
Meet financial criteria.
PART II – DENTAL INSURANCE COVERAGE
Do you, your spouse/common-law partner, or dependent children currently have dental insurance coverage
through a government program or private insurer?
Yes
No
Do you have Healthy Kids coverage?
Yes
No
All applicants must also complete the Dental Insurance Plan Verification Form.
PART III – PARENT/GUARDIAN INFORMATION (Please Print)
Last Name
First Name
Middle Name
Telephone Number
Daytime Telephone Number
Home Address (Street, Apartment #, City, Province, Postal Code)
E-mail address: ______________________________________
Consent to use e-mail:
Yes
No
Identification: Parent/Guardian must provide one piece of Photo ID
Driver’s License
Passport
Other: _______________________________________________________
A copy of the Photo ID must be provided with this application and an original must be presented at first appointment.
Address Confirmation: Minimum of ONE must be provided
Driver’s License
Utility Bill
Bank Statement
Other: _______________________________________________________________________________________
A copy of one of the above must be provided with this application and
an original must be presented at first appointment.
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