Save a Smile

Pee Dee Office Save a Smile Forms

For residents of Horry, Chesterfield, Lee, Darlington, Marlboro, Florence, Dillon, Marion, Williamsburg, and Georgetown

Client Intake Form

Enter below household information for every member in the household:

Monthly Income/Expense Information

Monthly Income

Monthly Expenses

Authorization for Client Participation in Media Relation Efforts

I am willing to have my picture(s) taken, video recorded and/or my voice recorded and grant Catholic Charities of South Carolina, The Diocese of Charleston, and other agencies participating in this event, to use my picture, my voice and physical surroundings without restriction for the purpose of Save A Smile, be it print, projection, internet website, video or any future media markets. I give my permission for Catholic Charities of South Carolina or representatives or any institution transmitting or exhibiting my picture or voice from any claims arising from such use or distribution. I agree to be fully responsible for my own participation and hold Catholic Charities of South Carolina or representatives harmless from any liability, loss of expense arising from the use of my picture or voice. I also consent to the use of my name, my voice and/or picture, and other material about me from promotional, publicity, or organizational purposes.

Release to Obtain and Disclose Information

By signing below, I am authorizing Catholic Charities to obtain my dental records of care from the provider(s) listed below:

I understand that my records are protected under the Federal Confidentiality Regulations as well as the provisions of HIPAA of 1996 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that I may revoke this consent at any time, provided that action has not been taken in reliance upon this authorization. Without written notice to withdraw this consent, it expires at the earlier of the listed expiration date or upon release of the information. The nature of this consent form has been explained to me and I understand its contents.

Save a Smile Program Agreement

This statement defines and outlines the process for helping clients obtaining services from Saxton Dental (denture provider) and Catholic Charities (guarantor). Client initials are required and indicate client reviewed and understands the program guidelines.

Client is responsible for arriving to all appointments on time.

 Client is responsible for attending and/or rescheduling all appointments.

Client is responsible for attending all appointments with CCPD Case Manager

Client is responsible for communicating with CCPD staff member with any issues.

Client understands that CCPD is only providing payment for denture services as outlined per agreement with Sexton Dental.

Services include: Economy Dentures (basic)

Full set dentures

Full upper or full lower dentures

Upper or lower partial denture

Client understands that CCPD is not responsible for payment of any additional services that are required and/or requested which may include: - Full mouth X-Rays, Extraction(s), Soft and/or Hard Relines, Adjustments, Crowns, Implants

Client is responsible for his/her portion of the payment and the client agrees to pay this amount directly to Sexton Dental.

Client understands that this agreement is effective on the date of signature and is only effective for 30 days. If the client requires more than 30 days for services to be provided, the client must contact CCPD Case Manager immediately for further discussion.