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;
~1~

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 EducationOffice 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
o
o
o
o
o

Number of schools served
Number of children served
Number of priority schools served
Number of children served in priority schools
Number of students requiring emergent care and follow-up
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.
~2~

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).
~3~
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
~4~