Brown Mobile Dental - Forms

Mobile Dental FormsBelow are instructions for you to follow in setting up an appointment. For clarification or additional information, contact our office.

Medicaid Patients with Applied Income

  1. Complete the Dental Referral form.
  2. Complete an H1263B form. For instructions on how to do so, click here.
  3. Read about your rights to privacy under HIPAA and sign your acknowledgement of your rights in our “Privacy Notice form.
  4. Fax or email Dental Referral Form, Privacy Acknowledgement form, and pages 1-2 of the H1263B form to our office so that we can get prepared to schedule your appointment.
  5. Mail pages 1-2 of the original H1263B form to our mailing address.

Private Pay Appointment

  1. Complete our Pay Agreement Form.
  2. Sign our Acknowledgment of Privacy Notice Form.
  3. Fax/Mail the above forms to PO Box 122295, Fort Worth, TX 76121. Include a check for the initial exam fee.

Downloadable Forms:

Dental Referral
How to Submit a Referral
How to Complete an H1263B
Privacy Notice
Private Pay Agreement