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Charitable Tracking Form

The Michigan Dental Association has developed a charitable contribution form for its members, which can be accessed using the links below. This form will help the MDA track charitable dental care performed by members across the state. The MDA encourages you to make copies of this form and to begin using it. It's very important that using this form becomes second nature to you and your staff. The form is easy to use with non-identifying basic information such as the local dental society where the charitable care was given, the patient's age, the ADA procedure code, and the value of the charitable care provided.

When completed, simply return the form to the MDA by either fax or through the mail. The form is available for download below in both Adobe .pdf format or Microsoft Word formats.

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