Application for initial anesthesia and sedation permits and certificates do not use this form if you presently hold a general anesthesia or parenteral se



Download 47.25 Kb.
Date06.12.2016
Size47.25 Kb.


MARYLAND STATE BOARD OF DENTAL EXAMINERS

Spring Grove Hospital Center • Benjamin Rush Building

55 Wade Avenue • Tulip Drive

Catonsville, Maryland 21228

PH: (410) 402-8501 FAX: (410) 402-8505


APPLICATION FOR INITIAL ANESTHESIA

AND SEDATION PERMITS AND CERTIFICATES



DO NOT USE THIS FORM IF YOU PRESENTLY HOLD A GENERAL ANESTHESIA OR PARENTERAL SEDATION ADMINISTRATON PERMIT WHICH IS SOON TO EXPIRE AND YOU WISH TO CONVERT THE PERMIT TO A CLASS I, CLASS II, OR CLASS III PERMIT. THERE IS ANOTHER FORM FOR THAT PURPOSE.
DO NOT USE THIS FORM IF YOU WISH TO RENEW A CLASS I, CLASS II, OR CLASS III PERMIT OR WISH TO RENEW A CERTIFICATE FOR A TREATING DENTIST TO ALLOW ANOTHER DENTIST OR PHYSICIAN TO ADMINISTER AT THE SITE OF THE TREATING DENTIST, OR TO RENEW A CERTIFICATE TO ALLOW A TREATING DENTIST TO TREAT A PATIENT AT A SITE AT WHICH ANESTHESIA AND SEDATION ARE ADMINISTERED, OR TO RENEW A CERTIFICATE TO ALLOW A CERTIFIED REGISTERED NURSE ANESTHETIST TO ADMINISTER ANESTHESIA AND SEDATION. THERE IS ANOTHER FORM FOR THESE PURPOSES.
THIS FORM SHALL NOT BE USED BY THE UNIVERSITY OF MARYLAND DENTAL SCHOOL FOR ITS PERMITS.
Dentists submitting an application must include a non-refundable check or money order made payable to the Maryland State Board of Dental Examiners in the amount(s) indicated on the attached list of fees.
This application must be completed for:
A. Class I permit
B. Class II permit
C. Class III permit
D. Class I, Class II, or Class III permit by exception – a dentist who has passed an administration and facility evaluation for a Class I, Class II, or Class III permit may receive a like permit for another facility or facilities if the facility or facilities for which the dentist seeks another permit has at least one dentist who has passed an administration and facility evaluation for a like permit at that location within 2 years of the date of application for the additional permit.

E. Class I, Class II, or Class III permit by exception – (Alternative) applicant holds a Class I, Class II or Class III permit and applicant and staff pass a facility and emergency evaluation for a like permit at the location at which an exception is sought. (Another dentist has not passed an administration and facility evaluation at the additional site within 2 years of the date of application for the additional permit.)


F. Certificate for a treating dentist to allow another dentist or physician to administer at the site of the treating dentist.
G. Certificate to allow a treating dentist to treat a patient at a site at which anesthesia and sedation are administered.
H. Certificate to allow a certified registered nurse anesthetist to administer anesthesia and sedation.

Complete the following

Dental License Number: _________________________ __

Name: ____________________________________________________________________

Address: _________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Telephone: _____________________________ Fax: __________________________

* Please Note the Nearest Maryland County _________________________ _

Location for which you seek a permit or certificate (include suite number if applicable).

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Indicate which of the above, A through H that you seek for this location: (for example, indicate A for a Class I Permit; B for a Class II Permit; and C for a Class III Permit, etc.)

______________________________________________________________________________
Second location for which you seek a permit or certificate (include suite number if applicable).

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Please note the Nearest Maryland County ________________________ _____

Indicate which of the above, A through H that you seek for this location:

______________________________________________________________________________
Third location for which you seek a permit or certificate (include suite number if applicable. Attach a separate sheet for additional locations).

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________
Indicate which of the above, A through H that you seek for this location:

______________________________________________________________________________



Exceptions to full administration and facility evaluation: Pursuant to COMAR 10.44.12 a dentist who has passed an administration and facility evaluation for a Class I, Class II, or Class III permit may receive a like permit for another facility or facilities if the facility or facilities for which the dentist seeks another permit has at least one dentist who has passed an administration and facility evaluation for a like permit at that location within 2 years of the date of application for the additional permit.
Alternatively, a dentist who has passed an administration and facility evaluation for a Class I, Class II, or Class III permit may receive a like permit for another facility or facilities if the dentist holds a Class I, Class II, or Class III permit for which the dentist has passed an administration and facility evaluation, and the dentist seeking the additional permit is present during a facility evaluation at which the dentist and the dentist’s staff pass a facility evaluation and, the dentist passes an evaluation, appropriate for the permit level, that includes simulated management of emergencies with the participation of the office staff trained to handle emergencies.
Location for which you seek a permit or permit and certificates in accordance with above exception (include suite number if applicable). If to your knowledge another dentist has passed an evaluation at that location within 2 years, please identify the dentist by full name and license number. If a dentist has not passed an evaluation at the location within 2 years you and your office staff will be required to meet the alternative criteria.

Full name and license number of dentist who has passed an evaluation at the location within 2 years, if applicable:

_____________________________________________________________________________

In addition, indicate which of the above, A through H that you seek for this location:


_____________________________________________________________________________
Second location for which you seek a permit or certificates in accordance with the exception (include suite number if applicable).

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Full name and license number of dentist who has passed an evaluation at the location within 2 years, if applicable:

_____________________________________________________________________________
In addition, indicate which of the above, A through H that you seek for this location:

_____________________________________________________________________________


THE REMAINDER OF THIS PAGE IS BLANK”QUALIFICATIONS FOR CLASS I PERMIT
In addition to the necessary qualifications listed below you must pass an administration evaluation and a facility evaluation.
1. Attach proof of successful completion of a Board-approved course of instruction that documents training of at least 24 hours of didactic education plus 20 clinically oriented experiences that provide competency in oral and combination inhalation-oral moderate sedation; OR (not both)
2. Attach proof of successful completion of a postdoctoral training program accredited by the Commission on Dental Accreditation or its successor organization that affords comprehensive and appropriate training necessary to administer and manage moderate enteral sedation.
Identify attached document by its date, institution, and individual’s signature:

______________________________________________________________________________

3. Attach a copy of your current certificate in either: Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), or proof of successful completion of a Board approved course of instruction on medical emergencies and airway management.
4. Have you ever treated a patient under deep sedation or general anesthesia with an incident? An “incident” means dental treatment performed on a patient under moderate sedation, deep sedation, or general anesthesia with unforeseen complications.
 YES  NO
If you answered Yes to question 4 attach an affidavit to this application. You must sign and date the affidavit which must contain the following language: “I solemnly affirm under the penalties of perjury that the contents of the foregoing affidavit are true to the best of my knowledge, information, and belief.” The affidavit must include at least the following:

a. The date of the incident;

b. The name, age, and address of the patient;

c. The patient’s original complete dental records;

d. The name and license number of the licensee and the name and address of all other persons present during the incident;

e. The address where the incident took place;

f. The preoperative physical condition of the patient;

g. The type of anesthesia and dosages of drugs administered to the patient;

h. The techniques used in administering the drugs;

i. Any adverse occurrence including:

(i) The patient’s signs and symptoms;

(ii) The treatments instituted in response to adverse occurrences;

(iii) The patient’s response to the treatment; and

(iv) The patient’s condition on termination of any procedures undertaken; and

j. A narrative description of the incident including approximate times and evolution of symptoms.
QUALIFICATIONS FOR A CLASS II PERMIT
In addition to the necessary qualifications listed below you must pass an administration evaluation and a facility evaluation.
1. Attach proof of successful completion of a Board-approved course of instruction that documents training of at least 60 hours of didactic instruction plus management of at least 20 patients per participant in moderate parenteral sedation techniques; OR (not both)
2. Attach proof of successful completion of a postdoctoral training program accredited by the Commission on Dental Accreditation or its successor organization that affords comprehensive and appropriate training necessary to administer and manage moderate parenteral sedation.
Identify attached document by its date, institution, and individual’s signature:

______________________________________________________________________________


3. Attach a copy of your current certificate in either Advanced Cardiac Life Support (ACLS) or Pediatric Advanced Life Support (PALS).
4. Have you ever treated a patient under deep sedation or general anesthesia with an incident. An “incident” means dental treatment performed on a patient under moderate sedation, deep sedation, or general anesthesia with unforeseen complications.
 YES  NO
If you answered Yes to question 4 attach an affidavit to this application. You must sign and date the affidavit which must contain the following language: “I solemnly affirm under the penalties of perjury that the contents of the foregoing affidavit are true to the best of my knowledge, information, and belief.” The affidavit must include at least the items identified in a. through j. of question 4 under Qualifications for Class I Permit above.

QUALIFICATIONS FOR A CLASS III PERMIT
In addition to the necessary qualifications listed below you must pass an administration evaluation and a facility evaluation.
1. Attach proof of successful completion of an advanced training program in anesthesia and related subjects beyond the undergraduate dental curriculum that is approved by the Board; OR (not both)
2. Attach proof of successful completion of a postdoctoral training program accredited by the Commission on Dental Accreditation or its successor organization that affords comprehensive and appropriate training necessary to administer and manage deep sedation and general anesthesia.
Identify attached document by its date, institution, and individual’s signature:

______________________________________________________________________________


3. Attach a copy of your current certificate in either Advanced Cardiac Life Support (ACLS) or Pediatric Advanced Life Support (PALS).
4. Have you ever treated a patient under deep sedation or general anesthesia with an incident? An “incident” means dental treatment performed on a patient under moderate sedation, deep sedation, or general anesthesia with unforeseen complications.
 YES  NO
If you answered Yes to question 4 attach an affidavit to this application. You must sign and date the affidavit which must contain the following language: “I solemnly affirm under the penalties of perjury that the contents of the foregoing affidavit are true to the best of my knowledge, information, and belief.” The affidavit must include at least the items identified in a. through j. of question 4 under Qualifications for Class I Permit above.

QUALIFICATIONS FOR CERTIFICATE TO ALLOW ANOTHER DENTIST OR PHYSICIAN TO ADMINISTER AT SITE OF TREATING DENTIST
A treating dentist who wishes to allow another dentist or physician to administer anesthesia and sedation to a patient at a specific practice location shall receive a certificate from the Board before allowing another dentist or physician to administer anesthesia and sedation at that location.
1. You must maintain either a Class I, Class II, or Class III Permit for each site at which you wish to allow another dentist or physician to administer anesthesia and sedation. You must also maintain a separate certificate for each site at which you wish to allow another dentist or physician to administer anesthesia and sedation.
I hold a:  Class I  Class II  Class III Permit
Location at which you hold a Class I, Class II, or Class III Permit

____________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________
2. Have you ever treated a patient under deep sedation or general anesthesia with an incident? An “incident” means dental treatment performed on a patient under moderate sedation, deep sedation, or general anesthesia with unforeseen complications.
 YES  NO
If you answered Yes to question 2 attach an affidavit to this application. You must sign and date the affidavit which must contain the following language: “I solemnly affirm under the penalties of perjury that the contents of the foregoing affidavit are true to the best of my knowledge, information, and belief.” The affidavit must include at least the items identified in a. through j. of question 4 under Qualifications for Class I Permit above.
3. Attach proof of successful completion of a Board-approved training program where you have received competent training in treating patients under moderate parenteral sedation and airway management; moderate parenteral sedation and airway management; deep sedation and airway management; or general anesthesia and airway management.
Identify attached document by its date, institution, and individual’s signature:

______________________________________________________________________________

4. You must maintain facility equipment in each facility consistent with a Class III Permit as outlined in the regulation titled Facility Evaluation Criteria.


QUALIFICATIONS FOR CERTIFICATE TO ALLOW A TREATING DENTIST

TO TREAT A PATIENT AT A SITE AT WHICH ANESTHESIA

AND SEDATION ARE ADMINISTERED
A treating dentist who treats a patient at a practice location other than the dentist’s own location, at which anesthesia and sedation are administered to the patient, shall receive a certificate from the Board before treating the patient.
This certificate is not specific to a particular practice location. You need only maintain a single certificate.
1. You must maintain a Class I, Class II, or Class III Permit at any location in Maryland.
I hold a:  Class I  Class II  Class III Permit
Location at which you hold a Class I, Class II, or Class III Permit

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


2. Have you ever treated a patient under deep sedation or general anesthesia with an incident? An “incident” means dental treatment performed on a patient under moderate sedation, deep sedation, or general anesthesia with unforeseen complications.
 YES  NO
If you answered Yes to question 2 attach an affidavit to this application. You must sign and date the affidavit which must contain the following language: “I solemnly affirm under the penalties of perjury that the contents of the foregoing affidavit are true to the best of my knowledge, information, and belief.” The affidavit must include at least the items identified in a. through j. of question 4 under Qualifications for Class I Permit above.
3. Attach proof of successful completion of a Board-approved training program where you have received competent training in treating patients under moderate parenteral sedation and airway management; moderate parenteral sedation and airway management; deep sedation and airway management; or general anesthesia and airway management.
Identify attached document by its date, institution, and individual’s signature:

______________________________________________________________________________




QUALIFICATIONS TO ALLOW A CERTIFIED REGISTERED NURSE ANESTHETIST TO ADMINISTER ANESTHESIA AND SEDATION
A treating dentist who wishes to allow a certified registered nurse anesthetist to administer anesthesia and sedation to a patient at a specific practice location shall receive a certificate from the Board before allowing a certified registered nurse anesthetist to administer anesthesia and sedation.
1. You must maintain either a Class I, Class II, or Class III Permit as appropriate for each site at which you wish to allow a certified registered nurse anesthetist to administer anesthesia and sedation. You must also maintain a separate certificate for each site at which you wish to allow a certified registered nurse anesthetist to administer anesthesia and sedation.
A treating dentist who allows a certified registered nurse anesthetist to administer moderate parenteral sedation to a patient shall maintain either a Class I, Class II, or Class III Permit for the administration site.
I hold a:  Class I,  Class II, or  Class III Permit for the administration site.
Location at which you hold a Class I, Class II, or Class III Permit.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________


A treating dentist who allows a certified registered nurse anesthetist to administer moderate parenteral sedation to a patient shall maintain either a Class II or Class III Permit for the administration site.
I hold a:  Class II or  Class III Permit for the administration site.

Location at which you hold a Class II or Class III Permit


_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________
A treating dentist who allows a certified registered nurse anesthetist to administer deep sedation or general anesthesia to a patient shall maintain a Class III Permit for the administration site.
I hold a:  Class III Permit for the administration site.
Location at which you hold a Class III Permit

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________


2. Have you ever treated a patient under deep sedation or general anesthesia with an incident? An “incident” means dental treatment performed on a patient under moderate sedation, deep sedation, or general anesthesia with unforeseen complications.
 YES  NO
If you answered Yes to question 2 attach an affidavit to this application. You must sign and date the affidavit which must contain the following language: “I solemnly affirm under the penalties of perjury that the contents of the foregoing affidavit are true to the best of my knowledge, information, and belief.” The affidavit must include at least the items identified in a. through j. of question 4 under Qualifications for Class I Permit above.
3. You must maintain facility equipment in each facility consistent with a Class III Permit as outlined in the regulation titled Facility Evaluation Criteria.

CHARACTER AND FITNESS

MUST BE ANSWERED BY ALL APPLICANTS

1. Have you ever held a general anesthesia administration permit, a parenteral sedation administration permit, a general anesthesia facility permit, or a parenteral sedation administration permit in Maryland?


 YES  NO

If you answered “YES” please provide the effective date(s) and the date(s) of expiration. For facility permits also include the location.

_____________________________________________________________________________

_____________________________________________________________________________


2. Have you ever held a general anesthesia administration permit, a parenteral sedation administration permit, a general anesthesia facility permit, a parenteral sedation administration permit, or any other anesthesia and sedation permit in any other state?

 YES  NO


If you answered “YES” please provide the effective date(s) and the date(s) of expiration. _____________________________________________________________________________
3. Have any investigations or charges been brought against you or are any currently pending in any jurisdiction, including Maryland, by any licensing or disciplinary board or any federal or state entity arising out of your administration of anesthesia or sedation or as a result of your ownership of a facility in which anesthesia or sedation was administered?
 YES  NO

If you answered “YES” please provide a detailed explanation on a separate page(s). Sign and date each page(s). If the investigations or charges resulted in any orders, reprimands, or administrative action, public or otherwise, attach a certified copy of each document. The certification must come from the issuing agency.


I have enclosed a check made payable to the Maryland State Board of Dental Examiners for $ __________________ as payment for the requested permits and or certificates.
I understand that once the Board begins the review process I will not be entitled to a refund of any fees paid.
Sign the Affidavit below if you have never treated a patient under deep sedation or general anesthesia with an incident. Do not sign the affidavit if you have ever treated a patient under deep sedation or general anesthesia with an incident. Instead, attach an affidavit as outlined in a. through j. of question 4 under Qualifications for Class I Permit above.
THE REMAINDER OF THIS PAGE IS BLANK”

Affidavit
I solemnly affirm under the penalties of perjury that I have never treated a patient under deep sedation or general anesthesia with an incident.
_______________________________________ __________________________

Applicant Signature Date

Release and Certification:
I hereby affirm that I have read and followed the above instructions. I hereby certify that all information in this application is accurate and correct.
I agree that the Maryland State Board of Dental Examiners may request any information necessary to process this application from any person or agency, including but not limited to postgraduate program directors, individual dentists, government agencies, the National Practitioner Data Bank, the Healthcare Integrity and Protection Data Bank, hospitals and other licensing bodies, and I agree that any person or agency may release to the Board the information requested. I also agree to sign any subsequent release for information that may be requested by the Board.
I agree that I will fully cooperate with any request for information or with any investigation related to my dental practice as a licensed dentist in the State of Maryland, including the subpoena of documents or records or the inspection of my dental practice.
During the period in which my application is being processed, I shall inform the Board within 2 business days of any change to any answer I originally gave in this application.
_______________________________________ __________________________

Applicant Signature Date

NOTARY
STATE OF
CITY/COUNTY OF
I HEREBY CERTIFY THAT on this day of , 20 , before me, a Notary Public of the State of Maryland and the City/County aforesaid, personally appeared before me and made oath in due form of law that signing the foregoing Application for Initial Anesthesia and Sedation Permits and Certificates was his\her voluntary act and deed.

AS WITNESS my hand and Notarial Seal.


Notary Public

My Commission Expires: SEAL
Fees for Permits and Certificates

Class I Permit - ($1000.00)


Class II Permit - ($1000.00)
Class III Permit - ($1000.00)
Class I or Class II Permit by exception - ($500.00)
Class I or Class II Permit by exception (Alternative - $700)
Class III Permit by exception - ($600.00)
Class III Permit by exception - (Alternative - $700.00)
Certificate for a treating dentist to allow another dentist or physician to administer at the site of the treating dentist - ($1000.00)
Certificate for a treating dentist to allow another dentist or physician to administer at the

Site of the treating dentist - additional location - ($300.00)


Certificate to allow a treating dentist to treat a patient at a site at which anesthesia and sedation are administered - ($1000.00)
Certificate to allow a treating dentist to treat a patient at a site at which anesthesia and sedation are administered - additional location - ($300.00)
Certificate to allow a certified registered nurse anesthetist to administer anesthesia and sedation -($1000.00)
Certificate to allow a certified registered nurse anesthetist to administer anesthesia and sedation - additional location - ($300.00)



Page


Directory: dental -> doc -> 2012
doc -> Introduction
doc -> 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8511 application for dental licensure by waiver of practical clinical examination notice For Mailing List
doc -> 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8510 application for dental hygiene licensure by waiver of practical clinical examination notice For Mailing List
2012 -> Application for dental licensure for dentists licensed in another state effective october
doc -> 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8511 application for volunteer dental licensure notice For Mailing List
2012 -> Dentist and dental auxiliary personnel
2012 -> Maryland state board of dental examiners
2012 -> Application for limited license to practice dentistry for graduates of u. S. And canadian dental schools section I general information
2012 -> Application for limited license to practice dentistry for graduates of dental schools outside the u. S or canada section I general information


Share with your friends:


The database is protected by copyright ©dentisty.org 2019
send message

    Main page