How To Apply

4 steps to completing the application process: 

1. VERIFY ELIGIBILITY

Patients who submit an application attest they are uninsured (do not have TennCare which now has dental coverage), are 19 years of age or older, are a U.S. Citizen and reside in East Tennessee to qualify for treatment.

 

2. COMPLETE ONLINE APPLICATION OR DOWNLOAD & COMPLETE FORMS

To save time, please fill out the application form at the bottom of this page. You may also download the forms linked on this page, then print and mail completed forms to the clinic. If you cannot download the forms, you may stop by the clinic to pick up copies of the forms.

3. GATHER PROOF OF INCOME*

Please provide ALL proof of income for your household which may include: gross wages, salary, tips, social security, pension, annuity, veteran’s benefits, alimony, child support, military family allotment, and others.

* If proof of income is not provided for all members in your household, your application will not be processed.

4. EMAIL, DROP OFF, or MAIL COMPLETED APPLICATION AND ALL REQUIRED DOCUMENTS TO:

Keystone Dental Care
603 Bert Street, Box 12
Johnson City, TN 37601

office@keystonedentaljc.com

THEN WHAT?

After your completed application is submitted with all required documentation, it will be reviewed and the information verified. When your application is approved you will be called and given an appointment time for a “New Patient Exam”. At this time you will be informed of your office fee.**

** All patients are charged on a sliding scale based on income.

Please note: Patients will have an office fee that will be collected before each appointment at time of service.  We use the 200% of Poverty guidelines and the payment will be based on household income.

Family Size         Annual Household Income 

1                         less than $30,120 or $2,510 monthly

2                         less than $40,880 or $3,407 monthly

3                         less than $51,640 or $4,303 monthly

4                         less than $62,400 or $5,200 monthly

5                         less than $73,160 or $6,097 monthly

6                         less than $83,920 or $6,993 monthly

7                         less than $94,680 or $7,890 monthly

8                         less than $105,440 or $8,787 monthly

Online Application

This online form will be the most efficient way to apply for services. Please fill out as accurately as possible and be prepared to bring in supplemental documents to your appointment where requested.

** IF THERE IS NO APPLICATION BELOW THIS LINE, IT MEANS APPLICATIONS ARE SUSPENDED DUE TO THE HIGH VOLUME OF NEW APPLICANTS – PLEASE CHECK AGAIN IN A FEW WEEKS **