Medicaid Online Screening - Smileworks Orthodontics

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Welcome to Smileworks Orthodontics! This page is designed for prospective orthodontic patients that have coverage through the Virginia Medicaid program to see if they are eligible to receive orthodontic treatment at our practice. Please be advised that there are 2 steps to the screening process. The first is for our practice and requires you to complete the form below from home. If we designate you as eligible, the 2nd step is for your insurance and requires you to come in to our practice for an appointment for orthodontic records. During this appointment, we will be taking photographs and 2 x-rays to submit to your insurance company. You will not be seeing Dr. Hussaini during this appointment. If your insurance approves coverage for your treatment, then we will schedule you an appointment with Dr. Hussaini to discuss your orthodontic treatment plan.

Please complete the information below for the patient that will be getting orthodontic treatment. We will then reach out to you and let you know what the next step will be for your treatment.

Name *

Name of Contact Person (if different from patient)

Date of Birth *

Best contact phone number *

Email address *

Does the patient have Medicaid coverage for dental insurance (patients that do will have a Medicaid ID number listed on their insurance card)? *YesNo

In your own words, what is your main concern with your smile? What would you like to see improved? *

When was the last time you had a cleaning with a general dentist? *

Do you have any active cavities? Do you have any history of gum/bone disease such as gingivitis or periodontitis? *

We are now going to request for you to submit 5 pictures so we can screen your case. It will be easier to have somebody else take these pictures, but they can certainly be taken yourself if need be.

Please take a picture of your top teeth as shown in the sample below. Open your mouth as wide as you can and take the picture pointing the camera at the roof of your mouth. *

Please take a picture of your bottom teeth as shown in the sample below. Open your mouth as wide as you can and take the picture pointing the camera at the bottom of your mouth. It is important to lift your tongue up when taking this picture so that the tongue is not covering the teeth. *

Please take a picture of the front of your bite as shown in the sample below. It is important to make sure your back teeth are biting down properly when taking this picture. In order to make sure your bite is correct, take your tongue and place it on the roof of your mouth, as far back as it will go. Once your tongue is in this position, bite down on your back teeth and maintain your bite in this position when taking this picture. *

Please take a picture of the right side of your bite as shown in the sample below. It is important to make sure your back teeth are biting down properly when taking this picture. In order to make sure your bite is correct, take your tongue and place it on the roof of your mouth, as far back as it will go. Once your tongue is in this position, bite down on your back teeth and maintain your bite in this position when taking this picture. *

Please take a picture of the left side of your bite as shown in the sample below. It is important to make sure your back teeth are biting down properly when taking this picture. In order to make sure your bite is correct, take your tongue and place it on the roof of your mouth, as far back as it will go. Once your tongue is in this position, bite down on your back teeth and maintain your bite in this position when taking this picture. *

That's it! Just hit submit below and one of our team members will reach out to you and let you know what will be your next step. Thank you for your time and we look forward to working with you!

Monday	10:00 am - 6:00 pm
Tuesday	9:00 am - 5:00 pm
Wednesday	9:00 am - 5:00 pm
Thursday	9:00 am - 5:00 pm
Friday	9:00 am - 4:00 pm