Dental Assistance Program

Application Process

1. Download Required Forms: Download and complete the Dental Assistance Form

2. Complete HIPAA Form: Download, fill out, and include HIPAA Form with submission

3. Gather Supporting Documentation:
- Financial documents establishing financial need
- Dental plan (if applicable)
- Dental provider statements or quotes
- Proof of insurance coverage/denials

4. Submit Application:
- Email completed application and all supporting documentation to: charity@vikingsofsolvang.org

5. Follow-up: Organization may contact applicant to request additional information

Required Information

• First Name, Last Name
• Email, Phone
• Full Address (Address Line 1, Address Line 2, City, State, Zip Code, Country)
• Years at current address
• Date of Birth
• Name of Parent/Guardian (if applicable)
• Description of dental condition and how organization can best serve you
• Insurance information
• Dentist information
• Date of Last Visit