Forms – Dental/Vision

 Note: All forms must be downloaded. Information cannot be entered online.


Application- Citizens 2015
Enrollment in the Special Care Insurance Program requires an application to be filled out and signed either by the facility (Account 1000) or by a family member (Accounts 2000, 3000, 3500, 5500). Once the applications are completed, SCS processes the applications by sending them to Citizens and sends the necessary paperwork to DHS to apply for the offset. (This process can be better understood by referring to the Flow Charts.)

Bank Draft Form for Electronic Payment
When the family member wants to pay the premium via an auto draft from a bank account, this form is used to collect the banking information which must be signed by the family member.

Change Form 2015
This Change form is filled out by your facility to notify SCS of a resident’s change in the program. (Transfers, expirations, family chooses to terminate the policy.)

Dental Only

Oral Screening Consent Form
This form is used for family (legal rep) authorization for a resident to be seen for the oral screening.

Total Vendor Consent Form
This form needs to be completed before a resident that is a total vendor can be seen by the dentist.

Fee for Service Consent Form
When you have a private pay resident who needs to be scheduled to see the dentist, a responsible party must sign this form prior to the dental visit.

ConceptBLU Order Form
When ordering ConceptBLU Oral Rinse, download this form and fax the completed order to 501-821-4311.

Paws 4 Seniors

Paws 4 Seniors Adoption Application – Canine Companion Program

Paws 4 Seniors Adoption Contract – Canine Companion Program