TCWD Healthy Smiles Quarterly Report
Reports are due within 60 days of the end of each quarter for recipients currently in their service commitment. An automatic email will be sent to your practice site contact to confirm your continued employment!
Name
*
First Name
Last Name
Email
*
example@example.com
Practice Site Name:
*
Facility/Organization
Practice Site Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Site Contact Email:
*
Administrator, Executive, Manager, etc.
You are a...
*
Dentist
Dental Hygienist
Dental Assistant
Reporting Year
*
Reporting Quarter
*
Q1 (Jan-Mar)
Q2 (Apr-Jun)
Q3 (Jul-Sep)
Q4 (Oct-Dec)
Reporting Quarter:
*
Please Select
Q1 (January- March)
Q2 (April- June)
Q3 (July-September)
Q4 (October-December)
Please select the quarter you saw patient numbers.
Total number of patients seen this quarter
*
Patients YOU have seen, not the total number for the practice site.
Number of TennCare/Medicaid patients seen this quarter
*
Number of Uninsured patients seen this quarter
*
Optional Comments:
Leave of absence this quarter, approved location switch, etc.
By signing below, I attest that the above information is true, and the numbers reflect my current employment with the practice site listed on this report.
*
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