Memorandum of Understanding (MOU) by and between Sauk County Public Health (Seal A Smile) and Dental Associates of Baraboo 12-15-2022

The Sauk County Health Department through the Seal-A-Smile program provides preventive dental care
and education with the mission of improving the oral health of Sauk County’s children.
The Sauk County Health Department has received a Healthy Community Partnership Grant from SSM 
Health St Clare Foundation which provides funds to establish a referral partnership between Sauk 
County Health Department Seal-A-Smile (referred thereafter as SAS) and Dental Associates of Baraboo 
for Baraboo students identified by SAS with urgent needs. Within that grant, funds are specifically 
provided to cover costs of supplies associated with care of referred students. All care will be 
provided in- kind by the staff of Dental Associates of Baraboo.
This MOU, between SAS and Baraboo Dental Associates expresses the intent of SAS to negotiate a MOU 
with Baraboo Dental Associates and to collaborate on this project as follows:
SAS will:
•  Identify students who meet qualifications of having both an urgent need as defined by 
the
Children’s Health Alliance of Wisconsin and no current dental home.
•  Seek permission of parent(s)/guardians to refer student to Baraboo Dental Associates
•  Obtain parent(s)/guardians’ digital or written acceptance of referral and understanding referral 
information shared with Baraboo Dental Associates may contain such health information as student 
name, date of birth, date of service with SAS, insurance status, parent name and contact 
information, and description of dental need.
•  Clarify in initial referral agreement with parent(s)/guardians that referral is only for student 
who has been identified with urgent need. Once this urgent need has been addressed, care covered 
under the granting program may be terminated. As such, once initial services to address the urgent 
need have been provided, families may expect to receive a letter from Baraboo Dental Associates 
outlining the termination of care, removing them as a patient of record.
•  Phone Dental Associates of Baraboo once signed referral agreement has been received to 
notify
staff of the new referral categorized under SAS as an “emergency slip.”
•  Follow up with Dental Associates of Baraboo throughout the program year to determine if patients 
have followed through with referral.
•  Monitor successes and challenges of referral program to share with Dental Associates staff and 
SSM Health St. Clare Foundation in continued improvement of partnership.
•  Defend, indemnify and hold harmless Dental Associates of Baraboo and its officers, directors, 
employees, representatives and insurers from any claims, suits, actions, losses, liens, damages,

Public Health Sauk County
West Square Building Third Floor, Suite 372
505 Broadway, Baraboo, WI 53913
PHONE (608) 355-3290 | FAX (608) 355-4329 |
VISIT US ONLINE co.sauk.wi.us/publichealth
liability, costs and/or expenses arising from or related in any manner to SAS’s obligations, 
conduct, acts or omissions under this Agreement and/or SAS’s participation in the Seal-A-Smile 
Program.
•  Provide Dental Associates of Baraboo with a copy of all consent forms and agreements intended to 
be provided to students and/or their legal guardians.

Baraboo Dental Associates will:
•  Work with families identified with urgent needs to set up appointments and provide initial care 
or additional referrals to address urgent needs
•  Bill Sauk County Public Health Seal-A-Smile Program for supplies used during care of referred 
students.
•  Monitor successes and challenges of referral program to share with SAS staff and SSM Health St. 
Clare Foundation in continued improvement of partnership.
•  Sign a separate Business Associate Agreement with Sauk County Public Health.

This MOU shall be effective for five years on approval, beginning September 15, 2022. Either party 
may terminate this Agreement at any time, with or without cause, by providing thirty (30) days
written notice to the other party.