Charitable Reporting


REPORT YOUR PRO BONO TREATMENT
If you provide charitable care in your office, please let us know about the services completed and population you treat. We are committed to compiling this data and communicating dentistry’s generosity to the public, the legislature and the media. Your participation will enhance our image as a profession.

Feel free to submit a separate sheet or superbill / printout if available.
Please do not report DDS or GKAS services provided.


NAME: ___________________________________________________
OFFICE: __________________________________________________
CITY/ST/ZIP: ______________________________________________
DATE(s) OF SERVICE: _______________________________________
AGE & SEX OF PATIENT: _____________________________________
TOTAL VALUE OF TX / CDT CODES: ____________________________


COMMUNITY CLINIC CARE
I volunteered at _________________________ clinic for a total of _________ hours during the (circle one) 1 2 3 4 quarter of 20_____.



Document all donations made in goods and services. Record full value and then deduct the discount even if the patient paid for a portion of services.

Submit documentation if available (no original records please)
Arizona Dental Foundation 3193 N Drinkwater, Scottsdale, 85251 FAX 480-344-1442