1. (a) An applicant for oral health services must be referred to the program by a third party nominator who knows the individual's economic condition.

2. (b) Each applicant for oral health services must complete or cause to be completed an application form which shall include the following:

   1. (1) personal information, including name, address, birthdate, gender and ethnicity;
   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 applicant or the person responsible for the applicant's support that: services are requested; the individual is a bona fide resident of Texas as set out in §49.5 of this title (relating to Eligibility Requirements); the family income does not exceed the financial guidelines; the applicant is not eligible for another program providing dental care, and the applicant or the person responsible for the applicant's support is financially unable to pay for all or part of the cost of the necessary treatment services.
3. (c) Each applicant who will be referred for oral health services or who will be served directly by the department must obtain preapproval from the regional dental director, or in his/her absence, the regional 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; amended to be effective March 23, 2003, 28 TexReg 2327.