Medicaid Value-Added Services Redemption Form Fill out the below information and click 'submit' to redeem your DentaQuest value added service reward. Member Information First Name: Last Name: Date of Birth: Mailing Address: City: State: TX Zip Code: Phone: ( ) - Second three digits Last four digits Medicaid Member ID Number: Date You Received Care: Your Plan: TX Medicaid What service did you receive at your dental appointment? Annual Preventive Care Reward: Age 6 months - 35 months: I had a dental check up todayAge 36 months - 5 years: I had a topical fluoride treatment todayAge 6 - 9 years: I got my 1st molars sealed todayAge 10 - 14 years: I got my 2nd molars sealed todayAge 15 - 20 years: I had my second cleaning today Dental Visit Within 90 Days Reward: Age 0 - 20 years: I had a dental checkup within 90 days of enrollment in Medicaid Emergency Room Follow-Up Care Reward: Age 0 - 20 years: I followed up with my Main Dentist and took the quiz within 30 days of a dental-related emergency room visit Your Child's Oral Health and the ER Quiz Take this quiz and test your knowledge. 1. Your child has a toothache. What should you do?: A. Call your child’s Main Dentist and schedule a visit as soon as possible.B. Wait and see if the toothache goes away on its own.C. Take your child to a hospital ER to be seen. 2. You took your child to a hospital ER for a toothache. What should you do next?: A. Wait and see if the problem goes away.B. Call your child’s Main Dentist and set up a follow-up visit.C. Plan on taking your child back to the hospital ER for additional care. 3. Your child has a toothache, but you don’t have a Main Dentist. What should you do?: A. Go to DentaQuest.com and log into the secure member Website to find a dentist online.B. Call DentaQuest member call center at 1-800-516-0165 and ask for help finding a dentist.C. A or B. 4. When should you call your dentist for an immediate visit?: A. Your child has a broken tooth or a tooth that has been knocked out.B. Your child has pain from a cavity or lost filling.C. Both A and B. 5. When should you take your child to a hospital ER for oral care?: A. Your child has a serious mouth injury or infection making it difficult to breathe or swallow.B. Your child may have a fractured or dislocated jaw.C. Both A and B.