Page 74 - 2021 MHA Start-up Guide

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2018-2019 MEMORANDUM OF UNDERSTANDING AGREEMENT
BETWEEN INSERT NAME OF SCHOOL &

INSERT NAME OF ORGANIZATION
This AGREEMENT for services is entered into INSERT DATE by and between the INSERT NAME OF
SCHOOL and INSERT NAME OF ORGANIZATION, a non-profit corporation.
INSERT NAME OF SCHOOL desires to engage INSERT NAME OF ORGANIZATION to render certain
charity care dental services within the ISO and INSERT NAME OF ORGANIZATION desires to perform
certain charity care dental services within the ISO.
Scope of Services
INSERT NAME OF ORGANIZATION will provide to the ISO during the term of the contract the following:
1. Campus Staff. INSERT NAME OF ORGANIZATION will provide each designated campus with a
Site Coordinator to help facilitate the coordination and scheduling INSERT NAME OF
ORGANIZATION's dental screenings and treatment on campus. INSERT NAME OF
ORGANIZATION will serve INSERT NAME OF SCHOOL elementary schools that are designated as
Title I Schools.

2. Supervision of Campus Staff. INSERT NAME OF ORGANIZATION clinical and administrative staff
will provide and be responsible for the supervision of INSERT NAME OF ORGANIZATION staff,
interns and volunteers serving each campus.

INSERT NAME OF ORGANIZATION will provide an array of basic dental and oral health education
services to treat students who have preventive and basic restorative dental needs. (See attached brochure
on patients served by INSERT NAME OF ORGANIZATION and treatment services offered).
Consents Required
a) For Screening: Parents/Guardians are provided an opportunity for passive consent to allow their child
to receive a non-invasive school-based dental screening, which provides INSERT NAME OF
ORGANIZATION with a high-level diagnosis of potential dental treatment needed. Parents/Guardians can
choose to have their child "opt-out" of this dental screening. Parent-Community Liaisons will assist in
distribution and retrieval of consent forms.
b) For Treatment: A formal consent form authorizing INSERT NAME OF ORGANIZATION to
perform dental treatment is distributed to parents for review and signature. Parents must return this form to
INSERT NAME OF ORGANIZATION will not provide dental treatment without a formal signed consent
from the parent/ guardian.
Data Needs
Healthcare Operations Data: In order to effectively and efficiently provide school-based dental services, INSERT
NAME OF ORGANIZATION requires each school to send detailed student roster information electronically to an
INSERT NAME OF ORGANIZATION administrator. Detailed student roster information will be provided through
the superintendent's office. (See Data Sharing Agreement.)

INSERT NAME OF ORGANIZATION Operational Service Requirements:
The ISO will provide to INSERT NAME OF ORGANIZATION at each service location during the term of the
contract the following:
1. Adequate confidential space to conduct dental screenings with portable equipment on campus for INSERT
NAME OF ORGANIZATION staff and program.
2. Safe and adequate parking for dental vans on campus to facilitate efficient dental treatment

3. INSERT NAME OF ORGANIZATION will be considered an agent of the ISO while performing duties
under this Agreement. INSERT NAME OF ORGANIZATION will be permitted access to personally
identifiable information subject to FERPA (20 U.S.C. 1232g). INSERT NAME OF ORGANIZATION
agrees to be under the direct control of the ISO and to be bound by the requirements of 34 C.F.R. 99.33 in
reviewing and disclosing any personally identifiable student information.

7 2 4. Use of campus copier MOBILE HEALTH CARE PROGRAM STAR T-UP GUIDE