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OFFICE USE ONLY CHECK LIST □ Application Receipt # □ Fee (if applicable) □ Anesthesia Form ID # □ Morbidity/Mortality Issue Date □ Training/Education □ Tax Addendum Permit # Rhode Island Board of Examiners in Dentistry Room 205 3 Capitol Hill Providence, RI 02908-5097 Instructions and License Application for: DENTAL ANESTHESIA PERMIT Check Below the Type of Permit you are applying for ‫‮‬ ‫‮‬ ‫‮‬ ‫‮‬ General Anesthesia/Deep Sedation Parenteral Conscious Sedation Nitrous Oxide Analgesia (No fee required) Inhalation Conscious Sedation “A” “B” “C” “E” Applicant - Print Name (First/MI/Last) Phone: (401) 222-2837 Fax: (401) 222-2158 TTY/TDD: (800) 745-5555 Revised 03/30/2012 GENERAL INFORMATION Pursuant to Chapter 5-31.1-1 of the General Laws of the State of Rhode Island the Rhode Island Board of Examiners in Dentistry it is required that any dentist licensed in this state administering or permitting the administration of, or intending to administer general anesthesia, or conscious sedation, or nitrous oxide analgesia in his or her dental office, must meet the statute and regulatory requirements and must hold a permit granted by the Board to administer or to permit the administration of general anesthesia, conscious sedation, nitrous oxide analgesia, or inhalation conscious sedation. Be advised that in addition to the personal anesthesia permit, each office location where general anesthesia, conscious sedation, or nitrous oxide analgesia are administered must obtain a facility permit. • Individual Permit Fee of $50.00 (no fee required for “C” Nitrous Oxide Permit) • Meet the educational training as forth by regulation. (see Appropriate Anesthesia Form) Rules and Regulations The rules and regulations governing the Practice of Dentistry can be obtained at the following web site: http://www.rules.state.ri.us/rules/released/pdf/DOH/DOH_3215.pdf Rhode Island General Laws pertaining to the Practice of Dentistry can be obtained at the following web sites: http://www.rilin.state.ri.us/statutes/title5/5-31.1/index.htm APPLICATION PROCESS OVERVIEW . Application Process You must submit your application and supporting credentials directly to the Board. The Board will use this information to assess your qualifications for the type of anesthesia permit you are applying for. You are responsible for notifying the Board office, in writing, if your address changes in the interim. The Board may be emailed an address change. The email address is located at the following web site. http://www.health.ri.gov/hsr/professions/dental.php HEALTH will not, for any reason, accelerate the processing of one applicant at the expense of others. Once completed, the application will be reviewed, and you will be contacted in writing. Please continue to review the remaining portions of this application packet for instructions and other materials necessary to complete the Board application. If you have any questions about this application process, or would like to check on the status of your Board application, please contact this office at (401) 222-2837. INSTRUCTIONS FOR COMPLETING THE BOARD APPLICATION Read the following instructions and those throughout the application packet carefully before completing the Board application. Failure to submit all required information and appropriate documentation may result in processing delays. All of the information provided is subject to change. General Instructions 1. Make a copy of the application and forms before you begin, in case you make a mistake. 2. Type your information or print in blue or black ballpoint pen. Board staff will not make assumptions about illegible information. Be sure to print your name in the box provided on the cover page. 3. Provide a response to each section or question; otherwise, mark “N/A” for Not Applicable. 4. We suggest that you make a copy of your completed application before submitting it to the Board. 5. It is your responsibility to check on the status of your application. Completing your Board Application: Complete all pages of the application, make a check or money order (in U.S. Funds only) for the application fee(s) of $50.00 (no fee required for Nitrous Oxide Permit “C”) payable to “Rhode Island General Treasurer” and staple it to the upper left-hand corner of the first (Top) page of the application. The application fees are NON-REFUNDABLE. Complete all application materials as instructed and arrange them in order as they appear in the application checklist. Do not submit applications without all applicable information, documentation and fee. Mail these components of the application to: Rhode Island Department of Health Board of Examiners in Dentistry, Room 205 3 Capitol Hill Providence, RI 02908-5097 Name:_____________________________________________ PERMIT “A” FORM GENERAL ANESTHESIA/DEEP SEDATION Permit A : Qualifications for – General Anesthesia/Deep Sedation: (Please check qualifying education/training) ( ) Completion of an advanced training program in anesthesia and related subjects beyond the undergraduate dental curriculum that satisfies the requirement described in Part II of the ADA Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry at the time training was commenced: or ( ) Completion of a ADA accredited post-doctoral training program (e.g., oral & maxillofacial surgery) which affords comprehensive and appropriate training necessary to administer and manage deep sedation/general anesthesia, commensurate with the ADA guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry; or ( ) I employ or practice in conjunction with a Board certified or Board eligible anesthesiologist IMPORTANT PLEASE SUBMIT THE FOLLOWING 1. Supporting official transcripts verifying the qualifications necessary for the requested permit. 2. A separate statement attesting that you have not been involved in any morbidity or mortality secondary to the administration of general anesthesia, conscious sedation or nitrous oxide analgesia. If you have been involved, please submit a full description on a separate page. 3. A copy of your current certificate of successful completion of an Office Anesthesia Evaluation, if you have been evaluated by the Rhode Island Association of Oral and Maxillofacial Surgeons, Committee on Anesthesia. 4. Permit fee: $50.00 (payable to the General Treasurer, State of RI) Signature of Applicant:___________________________________ Name:_____________________________________________ PERMIT “B” FORM PARENTERAL CONSCIOUS SEDATION Permit B : Qualifications for – Parenteral Conscious Sedation: (Please check qualifying education/training) ( ) Completion of a comprehensive training program in Parenteral Conscious Sedation that satisfies the requirements described in Part III of the ADA Guidelines for Teaching the Comprehensive Control of Pain an Anxiety in Dentistry at the time training was commenced; OR ( ) Completion of an ADA accredited post-doctoral training program (e.g., general practice residency), which affords comprehensive and appropriate training necessary to administer and manage deep parenteral conscious sedation; ( ) Completion of an advanced training program in anesthesia and related subjects beyond the undergraduate dental curriculum that satisfies the requirements described in Part II of the ADA Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry at the time training was commenced; OR ( ) Completion of an ADA accredited post-doctoral training program (e.g., oral and Maxillofacial surgery) which affords comprehensive and appropriate training necessary to administer and manage deep sedation/general anesthesia, commensurate with the ADA Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry; OR ( ) I employ or practice in conjunction with a Board certified or Board eligible anesthesiologist. IMPORTANT PLEASE SUBMIT THE FOLLOWING 1. Supporting official transcripts verifying the qualifications necessary for the requested permit. 2. A separate statement attesting that you have not been involved in any morbidity or mortality secondary to the administration of general anesthesia, conscious sedation or nitrous oxide analgesia. If you have been involved, please submit a full description on a separate page. 3. A copy of your current certificate of successful completion of an Office Anesthesia Evaluation, if you have been evaluated by the Rhode Island Association of Oral and Maxillofacial Surgeons, Committee on Anesthesia. 4. Permit fee: $50.00 (payable to the General Treasurer, State of RI) Signature of Applicant:___________________________________ Name:_____________________________________________ PERMIT “C” FORM NITROUS OXIDE ANALGESIA Permit C : Qualifications for – Nitrous Oxide Analgesia: (Please check qualifying education/training) ( ) Completion of a nitrous oxide analgesia training program from a school accredited by the ADA, and whose training program is consistent with the provision of the “Guidelines for Teaching the Comprehensive Control of Pain an Anxiety in Dentistry, Part I, or Part III of the ADA Council on Dental Education and which includes clinical experience in the administration of nitrous oxide analgesia; OR ( ) Completion of training consistent with that described in Part I or Part III of the ADA Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry; OR ( ) Completion of an ADA accredited post-doctoral training program which affords comprehensive and appropriate training necessary to administer and manage inhalation conscious sedation IMPORTANT PLEASE SUBMIT THE FOLLOWING 1. Supporting official transcripts verifying the qualifications necessary for the requested permit. 2. A separate statement attesting that you have not been involved in any morbidity or mortality secondary to the administration of general anesthesia, conscious sedation or nitrous oxide analgesia. If you have been involved, please submit a full description on a separate page. 3. A copy of your current certificate of successful completion of an Office Anesthesia Evaluation, if you have been evaluated by the Rhode Island Association of Oral and Maxillofacial Surgeons, Committee on Anesthesia. 4. NO FEE REQUIRED Signature of Applicant:___________________________________ Name:____________________________________________ _ PERMIT “E” FORM INHALATION CONSCIOUS SEDATION Permit E : Qualifications for – Inhalation Conscious Sedation: (Please check qualifying education/training) ( ) Completion of training consistent with that described in Part I or Part III of the ADA Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry; OR ( ) Completion of an ADA accredited post-doctoral training program which affords comprehensive and appropriate training necessary to administer and manage inhalation conscious sedation; OR ( ) Completion of a comprehensive training program in parenteral conscious sedation that satisfies the requirements described in Part III of the ADA Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry at the time training was commenced; OR ( ) Completion of an ADA accredited post-doctoral training program (e.g., general practice residency), which affords comprehensive and appropriate training necessary to administer and manage deep parenteral conscious sedation; OR ( ) Completion of an advanced training program in anesthesia and related subjects beyond the undergraduate curriculum that satisfies the requirements described in Part II of the ADA “Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry” at the time training was commenced; OR ( ) Completion of an ADA accredited post-doctoral training program (e.g., oral and maxillofacial surgery) which affords comprehensive and appropriate training necessary to administer and manage deep sedation/general anesthesia, commensurate with the ADA “Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry”; OR ( ) I employ or practice in conjunction with a Board certified or Board eligible anesthesiologist IMPORTANT PLEASE SUBMIT THE FOLLOWING 1. Application and appropriate Anesthesia Permit Form (ie) A, B, C, or E 2. Supporting official transcripts verifying the qualifications necessary for the requested permit. 3. A separate statement attesting that you have not been involved in any morbidity or mortality secondary to the administration of general anesthesia, conscious sedation or nitrous oxide analgesia. If you have been involved, please submit a full description on a separate page. 4. A copy of your current certificate of successful completion of an Office Anesthesia Evaluation, if you have been evaluated by the Rhode Island Association of Oral and Maxillofacial Surgeons, Committee on Anesthesia. 5. Permit fee: $50.00 payable to the General Treasurer, State of RI (if applicable) Signature of Applicant:___________________________________ State of Rhode Island Board of Examiners in Dentistry Application for Anesthesia Permit CHECK TYPE OF ANESTHERSIA PERMIT YOU ARE APPLYING FOR General Anesthesia/Deep Sedation* “A” Parenteral Conscious Sedation* “B” Nitrous Oxide Analgesia* “C” Inhalation Conscious Sedation* “E” *Attach appropriate Permit Form (i.e.) A,B, C, or E 1. Name(s) first M last This is the name that will be printed on your License/Permit/Certificate and reported to those who inquire about your License/ Permit/ 2. Social Security Number 3. RI Dental License Number It is your responsibility to notify the board of all address changes. 4. Primary Business Name & Address Street City/Town State Zip This address will appear on the Department of Health web site. 5. Preferred Mailing Address Please check ONE □ □ Please use my Home Address as my preferred mailing address Please use my Business Address as my preferred mailing address 6. Qualifying Training/Education (supporting documentation verifying the qualifications necessary for the requested permit must be submitted) 7. Have you ever been involved in any morbidity or mortality secondary to the administration of general anesthesia, conscious sedation, inhalation conscious sedation, or nitrous oxide analgesia: YES NO 8. Affidavit of Applicant: Complete this section and sign in the presence of a notary public. Make sure that you and the notary public have completed all components accurately and completely. The foregoing instrument was acknowledged before me this _____________ day of ___________________, 20_______, by __________________________________ who is personally known to me or has produced ___________________________ as documentation and did / did not take an oath. Applicant’s Signature Notary Public SEAL , Rhode Island Department of Health 3 Capitol Hill, Room 205, Providence RI, 02908-5097 MANDATORY ADDENDUM TO LICENSE APPLICATION Tax Payer Status Affidavit / Identity Verification All persons applying or renewing any license, registration, permit or other authority (herein after called “licensee”) to conduct a business or occupation in the state of Rhode Island are required to file all applicable tax returns and pay all taxes owed to the state prior to receiving a license as mandated by state law (RIGL 5-76) except as noted below. In order to verify that the state is not owed taxes, licensees are required to provide their Social Security Number, or Federal Tax Identification Number (for businesses) as appropriate. These numbers will be transmitted to the Division of Taxation to verify tax status prior to the issuance of a license. Licensee Declaration □ I hereby declare, under penalty of perjury, that I have filed all required state tax returns and have paid all taxes owed. □ I have entered a written installment agreement to pay delinquent taxes that is satisfactory to the Tax Administrator. □ I am currently pursuing administrative review of taxes owed to the state. □ I am in federal bankruptcy. (Case # ___________________________ ) □ I am in state receivership. (Case # ___________________________ ) □ I have been discharged from Bankruptcy. (Case # ___________________________) Type of Professional/Business License for which you are applying ____________________________ ____________________________ Full Name (Please Print or Type) Social Security Number (or FEIN for Business) _____________________________________________ Signature ______________________________________ Phone Number (including area code if not 401) ___________________________________ ___________________________ Date Name of Business (If Applicable) This form must be completed, signed and attached to your license application for processing This form must be completed, signed and attached to your license application for processing APPLICATION CHECKLIST Please review the following checklist to ensure you have satisfied all components of the application process. I have included a check in the amount of $50.00 and have attached it to the upper left-hand corner of the first (cover/top) page of the application. I have arranged my Board Application materials in following order: 1. Fee (attached as instructed) 2. Board Application and Appropriate Anesthesia Form (i.e.) A, B, C, or E 3. Tax Addendum Form 4. Supporting educational/training documentation as required. 5. A separate statement attesting that you have not been involved in any morbidity or mortality secondary to the administration of general anesthesia, conscious sedation or nitrous oxide analgesia. If you have been involved, please submit a full description on a separate page. I have mailed the above application materials directly to the Licensing Office, Department of Health.