Dental Program – How to Apply

How to Apply for Funding

Please only submit one complete application per person. Incomplete applications (those with missing pages/signatures/contact information/selection of Dentist written on the application) will not be accepted as they cannot be processed. Before Downloading the application, please read and follow the instructions.

1. Complete and sign Page 1, complete and sign Pages 2-4 of the Application Packet.

2. Select a Network Dentist (if you do not have one) from the DENTISTS BY COUNTY Link. WRITE THE NAME OF THE SELECTED DENTIST ON THE APPLICATION (on the line Current Dentist). When selecting a dentist, ensure the dentist meets all of the applicant’s needs regarding sedation and location.
–OR–
Use an Out-of-Network Dentist. Please note, before you can be treated by the dentist and we pay for your services, the dentist must send to our office a W-9 Form and a copy of the Liability Insurance Certificate (click DENTISTS ONLY Link for Form). WRITE THE NAME OF THE SELECTED DENTIST ON THE APPLICATION (on the line Current Dentist). When selecting a dentist, ensure the dentist meets all of the applicant’s needs regarding sedation and location. Please carefully select Dentists for Applicants. Approvals may not be revised and an applicant is funded for one Treatment Plan without revision per contract year.

3. Return, to our office, by Email, Fax, or Mail THE COMPLETED AND SIGNED 4 PAGE APPLICATION PACKET, a COPY OF THE NEW PATIENT ESTIMATE or TREATMENT PLAN (if available), DO NOT RETURN the Notice of Privacy Practices for Protected Health Information-keep for your records.
Email: dental@arcflorida.org
Disclaimer: emailing Applications may not protect the Applicants’ Protected Health Information and/or Identity.
Fax: 850.921.0418

Mail: Attn: Dental Program, 
The Arc of Florida, 2898 Mahan Drive, Suite 1, Tallahassee, FL. 32308