Medicaid Online Screening

**Por favor haga clic aquí para enviar este formulario en Español.**

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.

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.

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!