Apply for Dental Services

I understand that this sworn statement is required by law because I have applied for a "state public benefit", as that term is defined under Section 24-76.5-102(3), C.R.S. (2016). I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this state public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under section 18-8-503 C.R.S. (2016), and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.

I voluntarily authorize and request disclosure to the Colorado Gerontological Society, Senior Answers and Services Division of such medical information as may be needed to provide the necessary care for me including through written, spoken and electronic communication.

What Information Will Be Disclosed?

All records and other information regarding dental assessments, recommended treatments, dental work performed as well as not performed or declined, referrals to other dental providers, and complicating medical conditions or other impairments, as well as information about how my impairments affect my ability to complete the authorized treatment plan.

Who May Disclose Information About Me?

All dental and medical sources including but not limited to: dentists, oral surgeons, hospitals, clinics, labs, physicians, psychologists, mental health workers, correctional, addiction treatment, VA health care facilities, social workers, case managers, case workers, rehabilitation counselors, consulting dental providers, employers, and others who may know about my condition such as the person who helps me fill out this form, family, interpreters, friends, neighbors, and public officials.

To Whom May Information Be Disclosed?

To the Colorado Gerontological Society, Colorado Department of Health Care Policy and Financing, and other agencies or organizations that fund or finance this program, or which help to administer this dental program, program auditors, dental providers, and other medical professionals consulted.

The Purpose of this Authorization

To determine the specific services for which this project will make a grant, to monitor the provision of services leading to successful completion of the authorized treatment plan, or terminate of treatments and the grant.

General Provisions

This authorization is good for five years from the date signed (next to my signature below). I authorize the use of a photocopy, faxed copy, or other electronic copy of this form for the disclosure of the information described above. I may write to the Colorado Gerontological Society to revoke this authorization at any time. The Colorado Gerontological Society will give me a copy of this authorization if I request it by phone or in writing.

I certify that the information I have provided in this application is true and complete to the best of my knowledge. I understand that the Colorado Gerontological Society will use this information to determine my eligibility for the Low Income Senior Dental Program.

By signing this application, I certify that the information contained in this application is true and to the best of my ability. Under penalty of perjury if I have falsified any of this information, I understand that my grant will be terminated and that I will be responsible for paying any monies paid on my behalf to the Colorado Gerontological Society within 10 days in which the grant is terminated. I also understand that failure to pay may result in further legal action.