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Loudoun County Health Department Eligibility for the Children’s Dental Clinic Please call [PHONE REDACTED] for more information about the eligibility process. YOU WILL NEED TO PROVIDE ONE DOCUMENT FROM EACH OF THESE CATEGORIES PICTURE IDENTIFICATION – Must present an identification of parent/guardian and child applying for services. • Driver’s License • Passport • Foreign Country ID • Green Card • School ID PROOF OF ADDRESS : with parent/guardian/patient name and current address • Driver’s License • Lease • Utility Bill • Doctor’s Office Bill PROOF OF INCOME: • Medicaid Card (MUST BE ACTIVE). • Lunch letter for the current school year (IT MUST BE FREE NOT REDUCED). • Last 3 paystubs with consecutive dates from all the members of your family. • If parent gets paid in cash or personal checks, you must present a statement from employer. • Income tax return ONLY if you are self-employed. • If parent(s)/guardian(s) receive unemployment benefits, food stamps, child support. Bring proof of such income. • Last 3 bank statements from your savings and/or checking accounts. To help expedite the eligibility process, you can make an appointment in advance by calling [PHONE REDACTED]. Remember to bring all the required documents. The eligibility process cannot be completed if you do not provide us all the above documents. DENTAL SERVICES ELIGIBILITY MUST BE RENEWED ANNUALLY.