1. (a) To apply for treatment services, an individual must be referred to the program by a third party nominator who knows the individual's economic condition.

2. (b) Each individual who applies for treatment services must complete or cause to be completed an application form which will include the following:

   1. (1) patient information, including name, address, birthdate, sex, and race;
   2. (2) a statement from the referring third party nominator that the treatment services are necessary to prevent or reduce the probability of pain, infection, or disease; and
   3. (3) a statement by the individual or the person responsible for the individual's support that services are requested, that the individual is a bona fide resident of Texas, that the family income does not exceed the financial guidelines, that the individual is not eligible for another program providing dental care, and that the individual or the person responsible for the individual's support is financially unable to pay for all or part of the cost of the necessary treatment services.

3. (c) Each applicant must be preapproved as follows before an individual will be referred to a provider for a dental examination.

   1. (1) For patients who will be referred for treatment to private providers, preapproval is given by the regional dental director, or in his/her absence, the regional medical director.
   2. (2) For patients who will be served by nonprivate providers, preapproval is given by the nonprivate provider's clinic director or his/her designee.
   3. (3) For patients who will be served directly by the department, preapproval is given by the regional dental director, or in his/her absence, the regional medical director, or his/her designee.
4. (d) The denial of any application will be in writing and will include the reason(s) for such denial. Unless the application is denied because program funds are reduced or curtailed, the individual applying for services has the right to an administrative review and a due process hearing as set out in § 49.12 of this title (relating to Appeals).
5. (e) An individual has the right to reapply for program coverage at any time when there is a change of situation or condition.

Source Note:The provisions of this §49.4 adopted to be effective September 9, 1986, 11 TexReg 3793.