Dma 635 form 2026

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The DMA 635 Form—Attestation of Pregnancy is a document used to confirm a patient's pregnancy status for Medicaid dental service eligibility. It requires the healthcare provider to attest that the patient is under their care, provide the estimated delivery date, and note any medical restrictions related to dental care. The form must be signed by the provider and presented by the patient to their dentist.

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Click ‘Get Form’ to open the DMA 635 form in the editor.
Begin by entering the patient's name in the designated field. Ensure that it is printed clearly for accurate identification.
Next, input the estimated date of delivery. This information is crucial for determining eligibility for Medicaid dental services.
If there are any medical limitations or restrictions regarding dental care, specify them in the provided section. If none, simply select 'None'.
Indicate any medications that the patient can receive, ensuring to check for allergies beforehand. List them clearly to avoid any confusion.
Finally, have the provider print their name and sign the form, along with dating it appropriately to validate the attestation.

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