Community and Home-Based Oral Healthcare Pilot Application

Current Part 1
Part 2
Part 3
Complete

Track 1: Home Healthcare Agency – EOHHS has grant funding of up to $124,000 to be split among the selected applicants.

Track 2: Public Health Dental Hygienist (PHDH) – EOHHS has grant funding of up to $100,000 to be split among the selected applicants.

Track 3: Dentists and Oral Surgeons in Private Practice or Federally Qualified Health Centers (FQHCs) – EOHHS has grant funding of up to $100,000 to be split among the selected applicants.

Agency and Agency Capacity – Identify which track this application is for:

Track 1: Home Healthcare Agency

Track 2: Public Health Dental Hygienist (PHDH)

Track 3: Dentists and Oral Surgeons in Private Practice or Federally Qualified Health Centers (FQHCs)

Track 1: Home Healthcare Agency

Agency Name

Agency Address

Address

City/Town

State

ZIP/Postal Code

Email Address

Phone

Track 2: Public Health Dental Hygienist (PHDH)

Name

DH License Number

PHDH License Number

Email Address

Address

City/Town

State

ZIP/Postal Code

Phone

Track 3: Dentists and Oral Surgeons in Private Practice or Federally Qualified Health Centers (FQHCs)

Practice Name

Practice Address

Address

City/Town

State

ZIP/Postal Code

Dentist License Number

Email Address

Phone