(b) The form must be signed by:

1. (1) The patient; or
2. (2) A parent or guardian if the patient is a minor or an incapacitated person.

(c) A consent form must include at a minimum:

1. (1) Name, address, telephone number, and license number of collaborative care hygienist and consulting dentist under which services are provided;
2. (2) Services to be provided;
3. (3) If the patient is a minor, the consent form must also contain the following questions and statement: Has the child had dental care in the past twelve months? Yes___ No___ Does the child have an appointment scheduled at the dental home where care is normally provided? Yes___ No___ If yes, please list the name and address of the dentist or dental home where the care was provided. _________________________ If yes, we recommend maintaining your relationship within a dental home and not receive services in a public setting. “I understand that I can choose to have dental hygiene services provided at the dental home where care is normally provided rather than a public setting. I understand that all dental hygiene care provided by the dental home I have used in the past or a collaborative care dental hygienist will reduce future benefits that the child may receive from private insurance, Medicaid (ARKids) or other third party provider of dental hygiene benefits for the remaining benefit period.”;
4. (4) If the patient is an adult, the consent form must be signed by the patient and contain the following statement: Have you received dental care in the past twelve months? Yes___ No___ Do you have an appointment scheduled at the dental home where care is normally provided? Yes___ No___ If yes, please list the name and address of the dentist or dental home where the care was provided. _______________________ If yes, we recommend maintaining your relationship within a dental home and not receive services in a public setting. “I understand that I can choose to have dental hygiene services provided at the dental home where care is normally provided rather than a public setting. I understand that all dental hygiene care provided by the dental home I have used in the past or a collaborative care dental hygienist will reduce future benefits that I may receive from private insurance, or other third party provider of dental hygiene benefits for the remaining benefit period.”; and
5. (5) If the patient is an incapacitated person, the form must be signed by the patient’s legal guardian and contain the following statements: Has the patient received dental care in the past twelve months? Yes___ No___ Does the patient have an appointment scheduled at the dental home where care is normally provided? Yes___ No___ If yes, please list the name and address of the dentist or dental home where the care was provided. _________________________ If yes, we recommend maintaining your relationship within a dental home and not receive services in a public setting. “I understand that I can choose to have dental hygiene services provided at the dental home where care is normally provided rather than a public setting. I understand that all dental hygiene care provided by the dental home I have used in the past or a collaborative care dental hygienist will reduce future benefits that the patient may receive from private insurance, or other third party provider of dental hygiene benefits for the remaining benefit period.”