The Pennsylvania school dental form most parents need is the Private Dentist Report (Form H514.027). Your child’s dentist completes it at a routine exam, you return it to the school nurse, and the nurse transfers the findings into the student’s permanent dental record. Pennsylvania requires a dental exam at three points in a child’s schooling: upon first entering school (kindergarten or first grade, depending on the district), in third grade, and in seventh grade.1Legal Information Institute. 28 Pa Code 23.3 – Dental Examinations The requirement applies to public and private school students alike.2Pennsylvania Code. 28 Pa Code 23.1 – Required Health Services
Which Form You Actually Need
Pennsylvania uses two separate dental documents, and parents routinely get them confused.
- The Private Dentist Report (Form H514.027) is the one you bring to your child’s dentist. Your dentist fills it out and signs it, and you return it to the school.
- The School Dental Health Record (Form HL514.47) is an internal school document. The school nurse or school dentist maintains it as a cumulative record across all the grades your child attends. Parents do not fill this one out.3Commonwealth of Pennsylvania. School Dental Health Record
You can download the Private Dentist Report from the Pennsylvania Department of Health’s Dental Health Program page or request a copy from your school’s health office.4Commonwealth of Pennsylvania. Private Dentist Report of Dental Examination/Screening of a Pupil of School Age5Commonwealth of Pennsylvania. Dental Health Program
What You Fill Out Before the Appointment
The top section of the Private Dentist Report is yours. Complete it before you arrive at the dentist’s office so the form isn’t left half-done in someone’s inbox. You’ll need:
- Your child’s full name, date of birth, and sex
- Current grade
- School district name (if your child attends a charter school, write the charter school’s name, not the geographic district)
- Home address
What the Dentist Fills Out
During the exam, the dentist records the clinical findings on the lower portion of the form. The main fields cover:
- Whether untreated decay is present
- Whether treated decay (prior fillings) is present
- Whether sealants have been placed on permanent molars
- A treatment urgency rating of none, early, or urgent3Commonwealth of Pennsylvania. School Dental Health Record
The dentist signs and dates the report and adds the practice address and phone number. The school cannot accept the form without that signature. An “urgent” rating signals to the school nurse that follow-up care is needed, and you should expect a call.
Pennsylvania encourages private exams over school screenings because they give your child continuity of care with a dentist who knows their history.1Legal Information Institute. 28 Pa Code 23.3 – Dental Examinations
Submitting the Form to the School
Return the completed Private Dentist Report to the school nurse’s office. Most districts accept a hard copy; some let you upload it through a secure student health portal. Deadlines vary. Some districts set an early-fall cutoff, others want the form before the school year begins, and a few give you most of the year. Call the health office and get the actual date for your district rather than assuming.
Once submitted, the nurse copies your dentist’s findings into the student’s cumulative School Dental Health Record. That record travels with your child if they move within Pennsylvania. If the receiving school doesn’t get an adequate dental record from the previous one, the student has to be examined again regardless of age or grade.1Legal Information Institute. 28 Pa Code 23.3 – Dental Examinations
What Happens If You Don’t Submit One
If no Private Dentist Report comes in, the district arranges a dental examination for your child.2Pennsylvania Code. 28 Pa Code 23.1 – Required Health Services A school dentist or a public health dental hygiene practitioner performs the screening on-site during the school day, and the district should notify parents in advance of the date.6Commonwealth of Pennsylvania. School Dental Health Program
School-provided screenings are free to families.1Legal Information Institute. 28 Pa Code 23.3 – Dental Examinations If you’d rather your child be seen by your own dentist, submit the Private Dentist Report before the district schedules the screening.
Religious Exemption
Pennsylvania allows parents to excuse a child from the mandated dental exam on religious grounds. Under 28 Pa. Code ยง 23.45, you must give the school administrator written evidence that the examination conflicts with your religious beliefs.7Pennsylvania Code. 28 Pa Code 23.45 – Objections to Examination on Religious Grounds The exemption is not automatic: the Department of Health can deny it if the unexamined child poses a substantial health risk to others. The dental exam rules do not include a separate philosophical or personal-belief exemption.
Paying for the Exam
A private pediatric dental exam typically runs about $50 to $200, depending on the dentist and whether a cleaning is included. Most private dental plans cover preventive exams for children, often with no copay, so check your coverage first.
Pennsylvania’s CHIP program covers preventive dental examinations once every six months for enrolled children.8InsureKidsNow.gov. Summary of Benefits Report for Pennsylvania, CHIP Children on Medicaid get dental coverage through the Early and Periodic Screening, Diagnostic, and Treatment benefit, which requires states to cover preventive and restorative dental services for anyone under 21.9Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment Either program covers the exam your child needs to satisfy the school requirement. Families without dental insurance who don’t qualify for CHIP or Medicaid can rely on the free school-provided screening.