Patient Information
Patient information forms may be downloaded below.

Nursing facilities residents who have Medicaid with an Applied Income are eligible for dental reimbursement. To establish that the resident has an applied income, the social worker should ask the business office manager. Residents who do not have an applied income are “Full Vendor” residents. Mobile Dental Care will submit the H1263b after dental work is complete. After Medicaid receives the H1263b, the resident’s Applied Income will be adjusted every month until the dental bill is paid in full. The resident must remain in the nursing facility until dental bill is paid completely.

  Name Date
Concerning Medicaid  
H1263-B Certification of No Medical Contraindication - Dental 10/2007
HIPAA - MDC Notice of Privacy Practices  
MDC Patient Referral Form  
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