Cooperative agreement for dental services

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(Community Dental Provider)

This agreement dated by and between

(Name of Head Start/Early Head Start Program) (Address of Head Start/Early Head Start Program)

(Name of Community Dental Provider) (Address of Community Dental Provider)

Hereinafter called Head Start/ Early Head Start and Dental Provider, agree to the following:
  1. Dental Provider Responsibilities:

The dental provider will conduct an oral examination of Head Start/Early Head Start children who are HFS/All Kids Dental Program (Medicaid eligible and non-Medicaid.) These examinations and services are to be provided in the dental office or clinic, unless prior approval has been obtained to provide these services in other settings.


Conduct a dental examination of each child. The dental health status of each child is to be recorded on the State of Illinois’ Proof of School Dental Examination Form. The examination will include, but not be limited to, the following:

      • An initial dental examination or periodic dental examination of the child, checking for obvious cavities, bleeding around the gums and drainage. The examination must be conducted using a mount mirror, explorer, and light (head or flash).

      • Physical assessment of oral tissues, including mucous membranes-gingivae, periodontal tissues, tongue, palate, and teeth.

      • Assessment and documentation of harmful oral habits, which may hinder the child’s development.

      • Physical assessment of the face, lips, and oral cavity.

      • Observation of the throat.

      • Diagnostic radiographs, whenever indicated.


    • Provide services required for the relief of infection and pain.

    • Provide dental prophylaxis.

    • Provide instruction in self-care oral hygiene procedures.

    • Provide topical application of fluoride utilizing acid fluoride phosphate (AFP).

    • Provide dental sealants to first permanent molars.


Review the dental and medical history for each child. Where there is no dental history, the provider will complete the Illinois Proof of School Dental Examination Form.


Identify the special dental needs of children with disabilities and recommend how they can be addressed, such as, arrangement or continuation of special/dental care, use of special equipment, special training for parents and staff or referral for additional services as indicated.


Where indicators of possible child abuse or neglect are observed, the provider is mandated to report the suspected abuse/neglect to the DCFS Hotline at 1-800-252- 2873 immediately.


At the time of the examination, develop a written plan of treatment and follow up, for dental defects diagnosed problems, discovered during the dental examination and/or diagnostic radiographs, including charting of all decay and/or restorations observed.

The purpose of the plan is to ensure that appropriate steps are taken to resolve all dental problems and concerns. The plan is to be developed using the Illinois Proof of School Dental Examination Form. The dental provider is responsible for the treatment plan. It is understood that:

    1. The Dental Provider will actively encourage parents to observe the service schedule outlined in the treatment plan.

    1. The Dental Provider will keep the parents informed regarding the progress and treatment of their child.

    1. The Dental Provider will involve parents in the overall health care of their child. Ongoing information sharing and dialogue concerning the problem or condition, treatment and prevention efforts are highly recommended.

    1. The Dental Provider will inform Head Start/Early Head Start staff, where children are enrolled, regarding service and treatment plan and scheduling. If children and their parents do not keep scheduled appointments, the provider will notify the Head Start/Early Head Start staff, as well as assist in rescheduling missed appointments.

    1. The Dental Provider will report on a regular basis to the Head Start/Early Head Start staff on the progress of children in treatment. The provider will also notify the Head Start/Early Head Start staff when children complete dental treatment by providing a

written record of services rendered.

    1. The Dental Provider agrees to refer children who are difficult to treat due to extensive dental problems that may exceed the general dentist’s knowledge and skills to another dentist that specializes in treating children.

    1. The Dental Provider agrees to inform Head Start/Early Head Start staff of all referrals.


The Dental provider will conduct individual consultations with parents upon completion of the examination and related services for the child and whenever needed during the course of the program.


Upon request, no more than two (2) dental health education workshops for groups of parents and staff will be provided. These workshops should serve to provide general dental information obtained as a result of the child’s dental examination, and/or general dental problems seen in this population. Workshop topics may include but not be limited to: oral health status and self-esteem, relationship between nutrition and dental health, baby bottle tooth decay, how to handle dental emergencies and dental sealant programs.
The session will be scheduled upon the initiative of the Head Start/Early Head Start center. The session will last approximately one half hour, with a fifteen-minute question and answer period. The dental provider will submit to the center the following documentation for each workshop: copy of the agenda, a brief report on the workshop/discussion and a copy of the attendance sheet. The fee for the session is

$45.00. When indicated, a bilingual Spanish/English health professional will conduct the workshop. Workshops are not to be translated while a general session in English is going on.


Head Start/Early Head Start will reimburse the dental provider at the rates established by Illinois’ Department of Healthcare and Family Services and administered by the assigned Managed Care Organization, Dentaquest or the like entity. The fees as follows:

    1. Case Management Fee: $8.00

The case management fee is a one-time charge payable upon the first visit and the provision of required services to the child. The case management fee covers those costs associated with implementing the program, which are not included in the fee for specific service, such as defined in overall responsibilities.


Code #



Comprehensive Oral Examination




Periodic Oral Evaluation




Prophylaxis- Office





D1203 or D1206



Sealant (per tooth)



      1. Additional services rendered to children will be reimbursed as detailed on the HFS Dental Program Fee Schedule. The fee schedule is attached. Treatment costs exceeding $300.00 for a single child will be prior approved by the designated Head Start /Early Head Start staff person at the center.

      1. The dental provider agrees to prepare and submit claims to DentaQuest or assigned Managed Care Organization for all Medicaid enrolled children. The Dental Provider further agrees that Head Start/Early Head Start will only be billed for services rendered to the non-Medicaid enrolled child.

      1. The dental provider will submit bills to the Head Start/Early Head Start program by the 10th of each month for services rendered during the preceding month. The bill will include the following information:

        • Date of examination or services rendered

        • List of services provided by child with corresponding ADA CDT code(s)

        • Child’s legal name and address

      1. The Head Start/Early Head Start fiscal year is December 1-November 30, therefore all bills must be submitted to the Head Start/Early Head Start center no later than December 10, of the current fiscal year to be considered for payment. Initial requests for payment received after this date will be returned to the provider unpaid.

II. Dental Records and Compliance

i) Dental Provider agrees to utilize the Case Management Form to contact parents or guardians of the HS/EHS child exhausting and documenting three attempts to schedule an examination and follow up dental treatment appointments. Once the Case Management Form is completed, it will be delivered to the HS/EHS site within two weeks of referral.

II) The Dental Follow-up Treatment Form will be filled out by the dental provider and returned to the HS/EHS site. (Following the child’s follow up visit for dental treatment at the contracted dental provider’s office.)
Monthly claims for payment will be mailed or delivered to:
Name of Head Start/Early Head Start Center:
Address: Zip Code:
Name and Title of Person bills are to be directed to:
The Head Start/Early Head Start program will send reimbursement for dental services to:
Name of Community Dentist:
Name of Agency:
Address: Zip Code:
Phone #:

  1. Head Start/Early Head Start Responsibilities:

    1. Head Start/Early Head Start will refer eligible non-Medicaid and Medicaid enrolled children to the designated provider personnel in order to schedule appointments for necessary preventive services and examinations. Parents will also be given the phone number, address of dental provider to schedule appointments.

    1. Head Start/Early Head Start will provide the dental provider with the Illinois Proof of School Dental Examination Form upon request.

    1. Head Start/Early Head Start will advise the dental provider of children who are being referred to the dental provider, utilizing the DFSS 3071, a referral form. The Head Start/Early Head Start program will provide the dental provider with information about children enrolled in the Medicaid program.

    1. Head Start/Early Head Start will review all requests for reimbursement to ensure the Early Head Start/Head Start dollar is the dollar of last resort. The Head Start/Early Head Start money is to be used when no other third party reimbursement is available to the family.

This agreement begins on _and will remain in effect, except for annual changes in the fee schedule, revisions in the Head Start/Early Head Start performance Standards, City and/or state licensing standards and/or DFSS requirements. Either party may terminate this agreement by giving 30 days’ notice.

Head Start/Early Head Start Director Dental Provider





Reviewed by DFSS:


DFSS: Revised: 07/2015


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