Instructions to Parent or Legal Guardian and Dentist

Dental Care for Children with Special Needs


1. Parent or Guardian must complete form #1. The next step is to locate the local Grotto representative (Dr of Smiles) to obtain Form #2-Attending Dentist Pre-Treatment Estimate form, the attending dentist needs to complete. To locate a Grotto representative, you can go to our web site: If there is no Grotto or Dr of Smiles in your state, please contact the Humanitarian Foundation Office at: 614-933-0711 to obtain Form #2 and for assistance in the processing of your application.

The parents select the dentist of their choice, make an appointment for an evaluation to determine the dental work needed and secure an estimate of charges for the proposed work. PLEASE NOTE: Any work proposed as well as charges, must be evaluated and approved by the Humanitarian Foundation BEFORE treatment is started, with the exception of the initial exam, prophy, fluoride and x-rays. Charges for the initial examination will be paid, regardless of the disposition of the application, providing the child qualifies for the program.

2. The dentist must complete all items and spaces on Form #2. The Dentist’s office may print a separate pre-treatment estimate, which must be attached to Form #2. The form must be signed by the local Dr. of Smiles. When no local Dr of Smiles is available, the Humanitarian Foundation Office will process the paperwork directly. All forms, including the pre-treatment estimate of services needed, with charges, must be submitted for approval PRIOR to actual treatment. At the bottom of Form #2, space is provided for estimated hospital and anesthesia costs along with estimated time needed. This space must be completed if the work is to be done in the hospital and if any of these charges are to be covered by the Humanitarian Foundation.

3. Completed Forms #1 and #2 are then to be given to the local Dr of Smiles for sponsorship by the local Grotto. He will promptly submit them to the Humanitarian Foundation Office for approval of the application. If no local Dr of Smiles is available, completed forms should be sent to the Humanitarian Foundation, 430 Beecher Rd., Gahanna, OH 43230-1797, for approval of the application. The dentist will be notified directly of the application’s status, after which the dental office will contact the parent and hospital/anesthesia, when applicable to set the appointment(s).

4. The Doctor of Smiles of the sponsoring Grotto will assist the parents if any problems arise or if they have any questions. If no Dr. of Smiles is available, please contact the Humanitarian Foundation directly.

5. Orthodontia, Major Jaw Surgery, Implants and Facial Re-constructive surgery are excluded under this program. The Dental Care for Children with Special Needs Program is made possible, primarily through the generosity of the members along with family and friends of the Grottoes of North America, a Masonic affiliated organization, through its Humanitarian Foundation with the cooperation of local Dentists and Hospitals. When insurance coverage is available for any portion of the billing, the Humanitarian Foundation is ALWAYS the secondary carrier, with the exception of Medicaid recipients, which often have full dental benefits (payment in full).