At every location we visit, Delta Dental works with a local site partner who helps secure a physical location, helps identify children in need of care, works with parents to complete the required paperwork and generally helps organize the mobile program visit. Please go to the links below for more detailed information about how to organize a visit from the Dakota Smiles program and for the patient forms that must be completed by parents.

Site Partner Information Site Partner Requirements A step-by-step guide to organize a Dakota Smiles visit. Site Partner HIPPA Agreement This document outlines the site partner requirements in terms of the Health Insurance Portabillity and Accountability Act. Does Your Child Need Dental Care A poster template to promote the program in your community. Site Partner Letter of Agreement A letter of agreement between the local site partner and the Delta Dental Philanthropic Fund. Parent Information Sheet A form that promotes the program to parents. Program Qualifications A sheet that outlines the program's qualifications to be seen.

Patient Forms

Patient Information Form
This form, to be completed and signed by parents or guardians, includes the child's dental and medical history, insurance information, immunization forms and consent forms.

Dakota Smiles Program Patient Rights
Form for parents outlining patient rights and responsibilities.

Notice of Privacy Practice
Patient notice of privacy practices.