Application and Eligibility Process

If you reside in Tennessee, Georgia, or Alabama, click on the application link to download and complete it. If you are unable to email the application to Smiles, please mail it to the address provided below. Please refrain from sending pictures of the application.

We MUST have Proof of All Income for every adult in the household over the age of 18, a copy of the patient’s Photo ID, and a copy of the patient’s Medical Insurance.

If you do not have a job or other way to prove income, please fill out the Declaration of Household Income form included with the application.

** Important Note **

If your phone number changes, you MUST call and give us your updated number. If you do not give us your new number, we will not be able to reach you.

In person applications accepted on Monday through Friday between 8 a.m. and 4 p.m.

MAIL APPLICATION TO:

SMILES, Inc.

170 Smith Lane

South Pittsburg, TN 37380

(You will be contacted to confirm your place on the waiting list.)