Public Health Dental Program Patient Eligibility Application Form (Page 2 of 2) in pdf

PART IV – DEPENDENT INFORMATION (Please Print)

Dependents: Please include all dependent children Grade 7 and under. Please attach copies of 2 pieces of

identification (one must be a BC Services Card and a Birth Certificate or Passport) for each child listed.

If more space is required, please attach separate sheet.

Date of Birth

Gender

Legal Name

BC Services Card Number

(Day/Month/Year)

(M or F)

PART V – TOTAL ANNUAL NET INCOME

Please provide a copy of your most recent Income Tax return(s), Canadian Revenue Notice of Assessment(s) or

GST Credit for parent/guardian (and spouse or common-law partner if applicable).

Are you living with a spouse or common-law partner?

Yes

Name of spouse or common-law partner ______________________________________________________

Parent/Guardian’s income

(Line 236 of Canadian Revenue Notice of Assessment,

Income Tax Return or GST Credit from previous year)

Spouse or common-law

(Line 236 of spouse’s or common-law partner’s Notice

partner’s income (if applicable)

of Assessment or Income Tax Return from previous year)

Total combined net income from

previous year

Add lines 1+2

PART VI – DECLARATION AND CONSENT

I/We declare that the information provided on this application is accurate and true to the best of my/our knowledge.

I/We understand that giving false or incomplete information may result in termination or suspension of service.

I/We understand that this information will be used to determine eligibility for dental services.

I/We understand that Healthy Kids plan eligibility may change and coverage will be confirmed monthly.

I/We understand dental insurance plan eligibility will be verified with my employer.

I/We understand that we will need to reapply annually to establish eligibility.

I/We understand there is a Cancellation/Broken Appointment policy and a $25 fee may be charged if appointments are

not cancelled in a timely manner.

Name of Applicant (please print)

Name of Spouse/Common-law partner if applicable

(please print)

Signature of Applicant

Signature of Spouse/Common-law partner

(if applicable)

Date

For office use only:

Verified by:

Date

Please e-mail, fax, mail or drop off the forms in person:

Contact information:

Vancouver Community Public Health Dental Program

Telephone: 604-675-3981

Robert and Lily Lee Family Community Health Centre

Facsimile: 604-872-0108

#210 – 1669 East Broadway, Vancouver, BC V5N 1V9

E-mail:

dentalhealth@vch.ca

Page 2 of 2

Public Health Dental Program Patient Eligibility Application Form Page 2

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