Thank you for expressing an interest in becoming a patient at Keystone Dental Care. We provide dental
services to UNDERSERVED residents of Northeast Tennessee aged 19 and over.

Keystone Dental Care complies with applicable federal civil rights laws and does not discriminate on the basis of
race, color, national origin, age, religion, sex, or disability.

 

How to Apply For Care:

1. Read ALL requirements on this page to ensure you qualify before completing the application
2. Collect ALL information you need to complete the application in advance 
3. Click the “Apply Now” link at the bottom of this page and complete the application. Once you begin the application, you must complete it in the same session or you will have to start again from the beginning.

Requirements:

NOTE: If you do not meet all of the requirements listed below, we may still be able to help you. We are now offering a limited set of flat fee dental services (extractions, dentures, partials and crowns) to anyone in need regardless of your insurance status. Complete this contact form here rather than applying on this page to inquire.

  • You must not have TennCare. If you are unsure, request a verification here.

  • You must be at least 19 years old

  • You must not have dental insurance

  • You must be a resident of Tennessee

  • You must have a valid Tennessee picture ID or drivers license

  • You must have a social security number or tax id number

  • You must fall within the yearly income limit based on your family size.  Use the charts below to determine your eligibility:

     

Step 1: Determine your family size:

Any children that you include in your Family Size must be your child, under the age of 18, and living in your household.
Example Family Size
You 1
You + Spouse 2
You + Spouse + Your child (under 18 living in your household) 3
You + Your child (under 18 living in your household) 2

Step 2: Determine your yearly income limit:

Using your Family Size from Step 1, find your maximum yearly income using this table. This number is the maximum you and your spouse can make combined to qualify. Do not include you child’s income in these numbers. This amount should include any employment, unemployment, social security, disability, pension, alimony, child support, food stamps, or any other forms of income for both you and your spouse combined.
Family Size Maximum Yearly Income (You + Spouse)
1 $31,300
2 $42,300
3 $53,300
4 $64,300
5 $75,300
6 $86,300
7 $97,300

 Information/Documents Needed:

  • Tennessee photo ID or Drivers License

  • Social security number

  • Proof of income for each income source listed for you and your spouse if applicable
    – If employed, submit one of the following: your most recent tax return, 1 month of paystubs, or a letter from your employer on company letterhead including your pay rate a, average number of hours worked per week, and your employer’s contact information and signature.
    – If receiving unemployment, submit your official unemployment letter stating the weekly award amount.
    – If receiving social security, disability, other pensions, alimony child support or food stamps, submit a picture of the award letter stating how much you receive.
    – if self employed, submit the first 2 pages of your 1040 Form from your last tax return and the Schedule C Form
    – If no income, you must be ready to provide the name and contact info for someone who will be responsible for your bill in the event you are unable to pay. This person maybe contacted to verify their agreement to pay if needed.

All SUPPORTING DOCUMENTS MUST ACCOMPANY THE COMPLETED APPLICATION. All information will be reviewed and verified. If approved, applicant will be contacted for an appointment slot.

 

IF THE “APPLY NOW” BUTTON IS NOT VISIBLE BELOW, WE HAVE TEMPORARLY CLOSED THE PORTAL DUE TO LIMITED APPOINTMENT SLOTS. In that case, check back regularly to see if we have reopened the portal.  If you need assistance with the application, you can call our office at (423) 232-7919 and choose option 5. You can also text your questions to (423) 232-7919. We will be answering all inquiries during normal business hours.

Patients without access to electronic devices or patients who need additional assistance completing the application may come to the office to complete the application during business hours on one of our devices. We have staff ready to assist you if needed. Thank you for choosing Keystone Dental for your oral health care!

*** IMPORTANT: This application has multiple parts. You must complete both the application and the medical history. Partial applications will not be submitted.

APPLY NOW!