The Dental Clinic at the Knox County Community Health Center provides routine dental care for children and adults including:
- Fillings
- Sealants
- X-Rays
- Cleanings
- Extractions (including Wisdom Teeth!)
- Child Dentistry
We have a full-time dentist, oral surgeon,
dental assistants and dental hygienists!
Paperwork
*NOTICE: By signing your name electronically and submitting the form(s), you acknowledge your electronic signature has the same legal validity as your manual signature.
Intake Packet
Intake Packet: Fillable Intake Paperwork
Spanish Intake Packet - PRINT ONLY (papeleo de admisión de pacientes - IMPRIMIR SOLO): Versión en Español - todos los servicios
Other Forms
Medications List: Additional Current Medications Form Versión en español - Lista de medicamentos adicionales
Sliding Fee Scale: SFS Application Versión en español - Escala móvil de tarifas
Payment Policy
- Payment is due at time of service.
- Minimum payment for self-pay patients is $20 for Dental.
- If patients do not have health insurance, a sliding fee schedule at 200% above federal poverty guidelines is offered to all patients who are eligible. Need help getting coverage? Visit HealthCare.gov for easy steps to get health insurance.
- Health Center staff can also assist patients with enrolling in health insurance or Medicaid if they qualify.
- We accept Cigna Dental, Delta Dental, CareSource, Molina and All Ohio Medicaid Plans.
- Patients are expected to pay the full sliding-fee-scale amount at the time of their appointment.
- At the time your appointment is made, you will be told how much you can expect to pay. If for some reason we need to do a procedure that was not planned, and you cannot pay in full, a statement will be given to you. The remaining balance will need to be paid before another appointment can be scheduled.
- KCCHC protects its patients from surprise medical bills for services and items provided by KCCHC through a combination of:
- compliance with requirements established under Section 330 of the Public Health Service Act and
- provision of Good Faith Estimates as outlined in Section 27966B-6 of the Federal No Surprises Act.
Appointments and Cancellations
- New Patients need to be scheduled for an exam and x-rays before any appointments for restorations can be made.
- If you cannot make a scheduled appointment, please notify us by phone, at least 24 hrs. in advance of the appointment. There is usually a waiting list of people needing an appointment, so if you can’t make yours, we would like to be able to offer the appointment time to someone else.
- If you do not call 24 hrs. in advance to cancel an appointment, it will be considered a “missed” appointment and could delay or prohibit future appointments.
- A missed appointment is any appointment in which the patient does not show up or call in advance to cancel or reschedule the appointment.
Knox County Community Health Center is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).
Notice of Privacy Practices - HIPAA
