Author: NCMC

Green Hills Head Start
Dental Examination

2025
2026

Child Information
Child’s Name:	Parent/Guardian Name:
Birthdate:	Address:
Head Start Location:
Medicaid/Private Insurance #:	Phone Number(s):

** Attention Dental Professional **
Head Start will pay ONLY if the child is NOT ELIGIBLE for Medicaid. A current denial of Medicaid from FSD must be on file before Head Start funds can be authorized for payment. You will receive a Record Treatment Form after the Examination and Diagnosis Form has been processed. If you have an emergency situation, please call (660)359-2214. Head Start, with recommendation of the Health Advisory Committee, has adopted the current Medicaid reimbursement rate for non-Medicaid children.
Oral Exam $34.00 Bite Wings 25.00
Prophylaxis 35.00 Fluoride 15.00
Examination Date: _____/_____/_____ Next Appointment: _____/_____/_____

Check if Performed		Priority Group
Prophylaxis:	_____	Needs Routine Care:	_____
Diagnostic Radiographs:	_____	Needs Attention Soon:	_____
Fluoride Treatment:	_____
Exam Only	_____

Treatment Needed:

Tooth # or Letter	Description of Service

_____________________________________ _____________________________________ ___________
Dentist Name (Please Print) Signature Date
Mail to: Green Hills Head Start, PO Box 177, Trenton, MO 64683 Phone: (660)359-2214 Fax: (660)359-5787