MEMORANDUM OF UNDERSTANDING/AGREEMENT (MOU/MOA)
This Memorandum of Understanding/Agreement (MOU/MOA) is made on (MM/DD/YYYY) by and between (County Name) County School District, (School District address), West Virginia, (Zip Code) hereinafter “(County Initial) CSD” and (Dental Provider/Business Name), (Dental Provider/Business Physical Address), West Virginia, (Zip Code), hereinafter “Dr(s). Provider(s) Last Name(s)”.
Purpose
This MOU will clearly identify the roles and responsibilities of each party as they relate to providing preventive dental services in the school setting to reduce the incidence of childhood caries (cavities) through the application of dental sealants and other preventive dental services to children who may not otherwise receive preventive dental services.
The parties undertake a MOU/MOA under the following terms and conditions:
TERM: The term of this agreement shall be one (1) school year and shall renew each subsequent school year unless terminated within the terms of this agreement.
MODIFICATION: Changes to this MOU/MOA may be made only by written agreement by both parties.
TERMINATION: Either party may terminate this agreement with a 30-day written notice without recourse, penalty or additional performance.
GOALS AND OBJECTIVES:
To partner to improve the health of (County Name) County students by offering school-based dental services to the students of (County Name) County Schools by providing preventive dental services to children in the school setting who might not otherwise receive dental care. The aim is to reduce the incidence of childhood caries (cavities) through the application of dental sealants and fluoride varnish.
OBLIGATIONS OF THE PARTIES:
(County Initial)CSD shall perform the following obligations:
· Provide contact information and phone numbers (including after hours’ numbers in case of emergencies or schedule changes) for each school that Dr(s). Provider(s) Last Name(s) is/are to visit so that schedules may be arranged;
· Make adequate space available in each school for Dr(s). Provider(s) Last Name(s) and his/her/their staff to provide the respective dental services;
· Maintain a safe and secure work environment for the dental providers and employees or others, such as drivers, maintenance personnel, etc., that may assist with delivery of those dental services;
· Notify Dr(s). Provider(s) Last Name(s) of any changes or interruptions that may conflict with his/her/their schedule for providing dental services at the (County Name) County Schools. This will include snow days, faculty senate days, etc.;
· Keep all information protected by the HIPAA and FERPA federal regulations and share information of Dr(s). Provider(s) Last Name(s) student dental records only by his/her/their written consent and consent of the student’s parent(s) or guardian(s);
· Provide dental examination forms for the students he/she/they is/are to see as dental patients;
· Provide quarterly and annual reports to the West Virginia Department of Education-Office of Special Programs and other interested parties regarding key aspects, outcomes and impacts of the program, based on information received from provider(s), including:
o Number of schools served
o Number of children served
o Number of priority schools served
o Number of children served in priority schools
o Number of students requiring emergent care and follow-up
o Dental sealant retention;
· Hold harmless Dr(s). Provider(s) Last Name(s) and any members of his/her/their dental team for injuries occurring in their presence to any person but unrelated directly to provision of dental services.
Dr(s). Provider(s) Last Name(s) shall perform the following obligations:
· Maintain professional liability insurance for his/her/their services;
· Employee associates, hygienists, assistants or others he/she/they deem/deems appropriate to perform the dental services;
· Offer examinations, preventive, restorative, and minimally-invasive dental procedures per standards of practice to cooperative students who have submitted appropriate active consent forms;
· Treat or document referral of all children who are deemed in need of emergent care (within 24 hours) as identified during the oral health assessment.
· Bill appropriate insurance for the services provided to assure cost effectiveness and sustainability.
· Make appropriate financial and treatment arrangements with the students and families of those students for dental services his/her/their office team will provide;
· Provide prophylaxis and oral health assessment, dental sealants and fluoride varnish to a target population in the West Virginia Public School System either by licensed dentist or public health dental hygienist.
· Input data pertaining to each visit into an electronic database using the data entry device provided. Data requirements include demographic information, oral health assessment findings, services provided, follow-up, etc.
· Adhere to all guidelines set forth in the Oral Disease Prevention Manual.
· Operate within the rules and regulations set forth by the West Virginia Board of Dentistry regarding mobile dentistry and portable units.
· Adhere to all OSHA regulations, including but not limited to infection control.
· Be responsible for assurance of establishment of dental homes for case management and continuation of care;
· Assist students with enrollment into Medicaid, CHIP and other insurance providers to assist with cost and assure all children regardless of their ability to pay have access to dental services;
· Arrange a schedule independently with each school he/she/they is/are to visit;
· Strive to apply dental sealants to as many second grade students in the identified schools as possible;
· Return to identified schools one year after the initial visit to check for sealant retention via random checks;
· Comply with HIPAA and FERPA regulations regarding information of students;
· Strive to obtain parental consent for bi-directional communication and information sharing between his/her/their practice, school/school nurse and regular doctor (if applicable) as necessary to promote optimal student health on an as needed basis with the understanding that this information will continue to be treated in a confidential manner (HIPAA/FERPA).
CONSIDERATION. No monetary compensation or consideration is given between the (County Name) County School District and Dr(s). Provider(s) Last Name(s) for this MOU/MOA. However, Dr(s). Provider(s) Last Name(s) shall be allowed to receive compensation for dental services from various arrangements via the student’s parent/guardian, insurances, etc.
CONFIDENTIALITY. Both parties acknowledge that all student information is to be kept confidential and will abide by this request.
SIGNATORIES. This Agreement shall be signed on behalf of (County Name) County School District by (County Superintendent name), Superintendent of (County Name) County Schools and on behalf of (Dental Provider/Business Name) by Dr(s). Provider(s) Last Name(s) and is effective as of the date first written above.
X Date:
(County Superintendent name),
Superintendent of (County Name) County Schools
X Date:
Dr. (Dentist First and Last Name), DDS
(Dental Provider/Business Name)
X (if applicable)
Dr. (Dentist First and Last Name), DDS
X (if applicable)
Dr. (Dentist First and Last Name), DDS
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