How to Become a Patient
At the Noor Dental Clinic, volunteers work together to provide free dental care for uninsured, low-income individuals who qualify for the clinic’s services. To qualify, you must meet our eligibility requirements and provide the required documents.
OUR PROCESS FOR SELECTING PATIENTS
1. Are you eligible? You should review our eligibility requirements below. Make sure you meet our requirements.
2. Complete the Noor Dental Clinic Application. You do NOT have to provide verification of income or proof of identity at this time.
3. PRELIMINARY ELIGIBILITY DETERMINATION. We will review your application. If you do NOT meet our requirements based on your statements on the Application form, we will notify you.
4. Eligibility Interview. Every month our staff will select applications for eligibility verification. You will be contacted to set up an appointment with us. On your scheduled appointment, you will be asked to bring in verification of your eligibility (see “What you must provide” below).
5. Dental Appointment. If you meet all eligibility requirements and have provided all necessary verifications, we will contact you for an appointment as openings become available in the coming months.
HOW TO APPLY
1. You must complete a Noor Dental Clinic Application form to apply for dental services.
To be eligible:
1. You must not have any type of dental insurance including: private dental insurance, government provided dental coverage, MediCal or CenCal.
2. Household income must not be more than 200% of the 2014 Federal Poverty Level for all household members (see chart below).
3. You must be 18 years old or older.
Note: Patients will be re-screened for Eligibility annually.
MAXIMUM HOUSEHOLD INCOME CHART
(200% 2014 Federal Poverty Level)
Number in Household Monthly Income Yearly Income
1 person $1,915 $22,980
2 persons $2,585 $31,020
3 persons $3,255 $39,060
4 persons $3,925 $47,100
5 persons $4,595 $55,140
6 persons $5,265 $63,180
7 persons $5,935 $71,220
8 persons $6,605 $79,260
For each additional person, add $9,900 per year.
2. WHAT TO BRING TO YOUR INTERVIEW:
Proof of Identity:
You will be asked to provide photo identification at your Eligibility interview such as a California Driver’s license, state-issued I.D. or U.S. Passport.
Proof of Income:
Each working member of the household must produce proof of income, including:
Federal tax return for the last year PLUS:
• Copy of the last three pay stubs from every person who works in the household;
• Unemployment benefits statement and proof of current payment history;
• Proof of social security/disability income or retirement/pension benefits. If you have direct deposit for these checks, you must provide a bank statement;
• Child support/alimony support documentation.
• If you are paid in cash, your employer must provide a letter verifying your income with contact information.
• If self-employed, bring a Profit and Loss statement or a record of state tax sales revenue for past year.
• If living on savings, you must provide three of your most recent bank statements.
• If no income, we require a letter of support from the person who provides food and shelter for you.
Members of an immediate family who live in the same residence make up a household. That includes parents, sons, daughters, grandparents and children for whom the parents have legal custody.
Children living in the same household as their parents, under the age of 18, will be considered part of the household. Children who do not live with their parents may be included on an application if the parent can show that they support the child financially.
Proof of identity must be provided for each member of the household listed on your application.
Others living in the household, such as sisters, brothers, aunts, uncles or friends must apply separately.
A single person who lives alone or resides with others but does not qualify as a member of their household.
Important Information about the Noor Dental Clinic
• NOOR DENTAL CLINIC is not a walk-in clinic. Patients must complete an application form and be eligible for services. We see patients by appointment only.
• NOOR DENTAL CLINIC does not provide services for individuals whose injuries are covered by Worker’s compensation or for individuals seeking payments for injury through lawsuit or legal action.
• NOOR DENTAL CLINIC DOES NOT PRESCRIBE OR DISPENSE CONTROLLED SUBSTANCES OR NARCOTICS.
• In order to receive services when you need an interpreter, you must bring one with you that is over the age of 18 years and able to speak English fluently.
• NOOR DENTAL CLINIC is staffed primarily by volunteers who give their time without compensation.
• NOOR DENTAL CLINIC is supported by contributions from individuals, businesses and foundations, grants and patient donations.
• Your personal information is confidential and will be shared only with medical providers participating in your care.
• The Noor Dental Clinic does not discriminate against patients on the basis of race, sex, color, age, national origin, sexual orientation or disability.