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Milwaukee County Dental Access Directory
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1.
Dental Clinic Name
(Required.)
*
2.
Address of Clinic
(Required.)
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Phone Number
*
3.
Hours of Dental Clinic
(Required.)
Days of week and hours
*
4.
Dental Services Provided
(Required.)
Prevention services
General restorative
Endodontics
Oral surgery
Periodontics
Pediatrics
Other (please specify)
5.
Special populations served
Pediatrics
Pregnant women
Differently abled
Homeless
Adults only
All ages
Other (please specify)
*
6.
Payer Population
(Required.)
Medicaid/Badger Care
Uninsured
Commercial insurance
Other (please specify)
7.
Required Documents
Insurance card (if applicable)
Proof of income
Photo identification
Medical history
Co-pays (if applicable)
Other (please specify)
8.
Payment practices
Self-pay
Sliding fee scale
Clinic bills 3rd party payer
Free to all eligible patients
Other (please specify)
9.
Languages
*
10.
Contact Information
(Required.)
Name
Email Address
Phone Number
Current Progress,
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