Register as a Dental Patient
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Step 1
Before you submit your forms please call our scheduling department to coordinate your appointment:
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Step 2
Complete the Registration and Consent forms:
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Step 3
Complete the applicable Medical History forms:
Your Payment Options
We Accept Most Major Insurances. We accept most major insurances, AHCCCS Plans, and Medicare. Bring your health insurance card and a picture ID to your appointment.
MHC Healthcare also assists patients in screening eligibility for a variety of medical coverage options or discount programs such as Arizona’s Medicaid Program (AHCCCS) and Pima Community Access Program (PCAP).
Sliding Fee Scale (SFS)
The Sliding Fee Scale (SFS) is MHC Healthcare’s discounted health services program that makes healthcare affordable for you and your family. Based on gross family income, the SFS outlines the percentage or portion of billed charges that the client will be responsible for paying. All patients can be screened for eligibility for SFS discounts.
SFS Eligibility Requirements
- Have a gross annual FAMILY income no greater than 200% of the Federal Poverty Level guidelines.
- Must provide documentation of income and residency. You will be assigned to our SFS program while waiting for approval from AHCCCS. Attention Dental Patients on SFS: 50% of your dental fee must be paid at time of service.
Documents Needed to Complete Your Health-E-Arizona Plus Application & SFS
The items listed below will be required to determine your eligibility. Please bring all CURRENT information for your appointment.
- SOCIAL SECURITY CARD, PHOTO IDENTIFICATION, PERMANENT RESIDENT CARD, BIRTH CERTIFICATE for EVERYONE in household (spouse, children) even if you are only applying for yourself. BRING ORIGINALS we will make copies.
- PROOF OF ADDRESS – A current utility bill (electric, gas, garbage, water) with the applicant’s name.
- If you are living with someone and have no utilities in your name then a letter and current utility bill will be needed from the person you are living with. Letter must state EVERYONE that lives in the home, also list rent/ utilities amounts paid by applicant and the address. Must be signed and dated for the day of appointment. If applying for PCAP letter must be notarized.
- PROOF OF ALL INCOME IN HOUSEHOLD – If you or anyone in the household gets paid
- Every 2 weeks – Must have last 2 pay stubs. (MOST Current)
- Twice a month- Must have last 2 pay stubs. (MOST Current)
- Weekly- Must have last 4 pay stubs. (MOST Current)
- If receiving Unemployment, SSI, Social Security, Child Support, Pension, Property Income, Educational Assistance must bring in proof of this source of income. Award letters needed from all source listed above. (Bank statements will not be accepted)
- SELF EMPLOYED- Profit and Loss for the past year is needed or Income tax 1040 previous year.
- TERMINATED INCOME- If you or anyone in household recently lost a job you must bring a letter from the employer stating last day of employment.
- OTHER MEDICAL INSURANCE – If you or anyone in household has insurance other than AHCCCS you must bring insurance card or copy of the front and back of the card.
- PROOF OF PREGNANCY- Must have estimated date of delivery.
- ADDITIONAL DOCUMENTS NEEDED ONLY WHEN APPLYING FOR FOOD STAMPS AND CASH ASSISTANCE
- Registration or Title for all vehicle
- Current Bank Statement (Checking and Savings) for everyone in household
- Proof of Rent or Mortgage (Rental/lease agreement or receipt /Mortgage statement or coupon book)
- All Utility Bills ( Electric, Gas, Garbage, Sewer, Water, Telephone).
Arizona’s Medicaid Program (AHCCCS)
Arizona Health Care Cost Containment System (AHCCCS) is Arizona’s Medicaid agency that offers health care programs to serve Arizona residents. Individuals must meet certain income and other requirements to obtain services. Please visit http://www.azahcccs.gov/for more information.
Pima Community Access Program (PCAP)
Pima Community Access Program (PCAP) is a not-for-profit organization that provides access to professional health care at discounted prices that the uninsured can afford. Qualified participants pay an enrollment fee of $40 twice a year to participate. Beyond the enrollment fee, participants pay only when they use services. Most primary care is provided on a discounted sliding fee scale. Prior authorizations are not required, and there are no insurance forms to fill out or insurance plan requirements to meet. Please visit http://www.mypcap.org for more information.
Healthcare.Gov
Healthcare.gov is a web-based enrollment US government healthcare exchange created under the provisions of the Patient Protection and Affordable Care Act.
