TEXAS STA ATE BOARD D OF DENTAL L EXAMINER RS 333 Guadalu upe Street, Tow wer 3, Suite 800 Austin, Te exas 78701-3942 (512) 4 463-6400 | Fax: (512) 463-7452
[email protected] ov
Anesthesia Perrmit Application Instru uctions: Make e your check orr money order payable to TSB BDE. Processin ng may take up p to two weekss. All fields are e required. Subm mitting an incom mplete applicatiion will further delay the proce ess. The fee iss the same, whe ether you are a applying for one or more privile eges. Please note you must hold h an active Texas T dental lic cense prior to a applying for sed dation privilege es. PERM MIT SELECTIO ON ( ) Check one or both.
FEE
A the proo of of course co ompletion. Nitrrous Oxide: Attach vel 1 – Minima al Sedation: Iff applicable, provide the datte of the TSBD DE Nitrous Ox xide permit Lev issue ed __________ ___ AND attac ch the proof off course comp pletion that sp pecifies the nu umber of didac ctic hours and d clinical cases achieved du uring training.
$3 32.00
APPL LICANT INFOR RMATION Last N Name
First F Name
TX De ental License #
Day ytime Phone #
Midd dle Initial Em mail Address
Curre ent Address:
City
State
Zip
Permanent Address s:
City
State
Zip:
Work Address:
City
State
Zip
Prefe erred mailing ad ddress: (preferreed address will bee made available too the public) Current
Permanent
Work
Educ cation Denta al School
De egree
Graduation Ye ear
Post G Graduate Scho ool
Pro ogram
Year of Comp pletion
Otherr
Pro ogram
Year of Comp pletion
Practtice Informatio on Will yyou be providing dental servic ces at the same e location wherre you will adm minister anesthe esia? YES
NO
YES
NO
Will yyou be providing anesthesia services s to child dren under 13 years y old?
Anestthesia Applicattion
Ja anuary 2018
In acccordance with Section S 258.15 553 of the Texa as Occupations s Code, Will yo ou be providing anesthesia servicces in more tha an one location n?
YES
NO
YES
NO
YES
NO
Do yo ou have an emergency plan in n place? Do yo ou conduct eme ergency drills? If yes, how oftten?
LIFE SUPPORT CE ERTIFICATION NS: Attach a copy c of CPR Card C to this ap pplication.
BLS C CPR Issue Datte
BLS CPR E Expire Date
DISCIPLINARY HIS STORY AND LICENSE IN GO OOD STANDIN NG: In accorda ance with SBD DE Rule 110.2(b b)(4) - An appliicant for a sedattion/anesthesia a permit must be b licensed by and a should be in good standi ng with the Board. “Good Sta anding” means that the dentisst’s license is not n suspended,, whether or no ot the suspensio on is probated . Applications ffrom licensees who are not in n good standing g may n not be approve ed. All “Y Yes” answers MUST M be explaiined in detail in n a separate SIGNED and NO OTARIZED affid davit. The affid davit should incclude all releva ant dates and identify the rele evant jurisdictio on and/or entity y involved. Failu ure to disclose e any of the req quested informa ation may resultt in the denial of o your applicattion or other ap ppropriate actio on. 1 1. Have you been b the subje ect of any disciiplinary action and/or have a pending invesstigation YES S N NO from any lic censing authorrity or jurisdictio on? 2 2.
Have you been b arrested, charged, indic cted, convicted, pled nolo con ntendere or recceived a court orderr for any criminal offense?
YES S
N NO
3 3.
Have you had h a Drug En nforcement Adm ministration (DEA) registratio on denied, susp pended, placed on probation p or revoked?
S YES
N NO
4 4.
Have you relinquished an a anesthesia permit in any y jurisdiction o or with any pe ermitting authority? Have you ever e been the subject of a dis sciplinary inves stigation involvving the adminiistration of anesthesia/sedation in any jurisdiction?
S YES
N NO
YES S
N NO
5 5.
This section n was in ntentio onally le eft blan nk.
Anestthesia Applicattion
Ja anuary 2018
AFFIDAVIT OF APPLICANT APPLICATION NITROUS OXIDE PERMIT | LEVEL 1: MINIMAL SEDATION PERMIT I, the below named applicant, hereby declare under penalty of perjury that I am the person described and identified in this application and that my answers and all statements made by me on this application and accompanying attachments are true and correct. Should I furnish any false information, or have substantial omission, I hereby agree that such an act shall constitute cause for denial, suspension, or revocation of my license or permit to provide Nitrous Oxide or Level 1: Minimal Sedation. I also declare that if did not personally complete the foregoing application that I have fully read and confirmed that I have fully read and confirmed each question and accompanying answer, and take full responsibility for all answers contained in this application. I understand that I have no legal authority to administer Nitrous Oxide or Level 1: Minimal Sedation, until a permit has been granted. I certify that I am trained and capable of administering Basic Life Support and that I employ qualified auxiliary personnel to assist in monitoring a patient under Nitrous Oxide. Such personnel are trained in and capable of monitoring vital signs, assisting in emergency procedures, and administering basic life support. I understand that a dentist performing a procedure for which Nitrous Oxide or Level 1 Minimal Sedation is being employed shall not administer the pharmacologic agents and monitor the patient without the presence and assistance of at least one qualified auxiliary personnel. I understand that if a patient enters a deeper level of sedation than what I am qualified to provide, I must stop the dental procedure until the patient returns to the intended level of sedation. I understand that I am responsible for the sedative management, adequacy of the facility and staff, diagnosis and treatment of emergencies related to the administration of Nitrous Oxide or Level 1: Minimal Sedation and providing the equipment and protocols for patient rescue. I understand that I must be able to rescue patients who enter a deeper state of sedation than intended and must be prepared to treat emergencies that may arise from the administration of Nitrous Oxide/Oxygen Inhalation Sedation and Level 1: Minimal Sedation. I am aware that pursuant to Title 22, Chapter 108, of the Texas Administrative Code, I must report any adverse occurrences related to the use of sedation. I hereby authorize the release of any and all information and records the Board shall deem pertinent to the evaluation of this application, and shall supply to the Board of such records and information as requested for evaluation of my qualifications for a permit to administer moderate sedation in the State of Texas. I understand that based on evaluation of credentials, facilities, equipment, personnel, and procedures, the Board may place restrictions on the permit. I further state that I have read the rules related to the use of Anesthesia and Sedation as described in Title 22, Chapter 110, of the Texas Administration Code. I hereby agree to abide by the laws and rules pertaining to the practice of dentistry and anesthesia and sedation in the State of Texas. MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
SUBSCRIBED AND SWORN BEFORE ME, THIS _______________ DAY OF ______________, 20____.
NOTARY PUBLIC SIGNATURE: _______________________________________________________ (NOTARY SEAL) (TYPED OR PRINTED): _________________________________________________________
MY COMMISSION EXPIRES: __________________________________________________
Anesthesia Application
January 2018
GENE ERAL INFORM MATION: This application is s for a permit to t administer Nitrous Oxide e or administe er Minimal Sed dation – Levell 1 in the State e of Texas When n completing th his application, please be advised of the follo owing: Dentistss licensed in the State of Texa as shall obtain an anestthesia permit fo or the following g anesthesia prrocedures used d for the purposse of performin ng dentistry: (1) Nitrous Oxide//Oxygen Inhala ation Sedation; (2) Level 1: Minim mal Sedation; (3) Level 2: Mode erate Sedation limited to enterral routes of ad dministration; (4) Level 3: Mode erate Sedation which w includes s parenteral rou utes of adminisstration; or (5) Level 4: Deep Sedation or General Anesthe esia. Query Reports s: Self Q onal Practition ner Data Bank (NPDB): All applicants a are required r to com mplete a self-qu uery of the NPD DB. The report results must Natio remaiin in the origina al sealed envellope and be atttached to your application to tthe TSBDE. NP PDB self-queryy reports are va alid for 60 days. If you are app plying for more than one level of sedation, in one mailing, yyou may submiit one NPDB Se elf-Query Repo ort which will vels of sedation n. If you are ap pplying for seda ation privilegess on separate d dates you mustt submit a NPD DB Self-Query applyy towards all lev reportt with each ane esthesia permitt application. You Y can contact the NPDB at, (800) 767-673 32, or via the w website at http:///www.npdb.hrs sa.gov/pract/ho owToGetStarted d.jsp. Amerrican Associattion of Dental Boards (AAD DB) Clearingho ouse: Applican nts are required d to complete a self-query of the AADB Clearringhouse. The report results must remain in n the original se ealed envelope e and be attach hed to your app plication to the TSBDE. If you a are applying forr more than one e level of sedattion, in one ma ailing, you may submit one AA ADB Self-Querry Report which h will apply towarrds all levels off sedation. If yo ou are applying g for sedation privileges p on se eparate dates yyou must subm mit a AADB Selff-Query reportt with each ane esthesia permitt application. The T AADB self-query form can n be downloade ed from the AA ADB website att https:://www.dentalboards.org/Clea aringhouseQue eryForm.htm. The T AADB self--query form sh hould be mailed d to: American Association of De ental Boards, 21 11 East Chicag go Avenue, Suiite 760, Chicag go, IL 60611. T The AADB telep phone number is (312) 440-74 464. NITROUS OXIDE/O OXYGEN INHA ALATION SEDA ATION PERMIT Educ cation and Pro ofessional Req quirements: A den ntist applying fo or a Nitrous Ox xide/Oxygen Inh halation Sedation Permit musst meet ONE of the following educational/prrofessional requirrements listed below and sub bmit proof of co ourse completio on: __ __ Completion of o a comprehen nsive training program p consis stent with that d described for n nitrous oxide/oxxygen inhalatio on sedation adm ministration in the t American Dental D Association (ADA) Guiidelines for Tea aching Pain Co ontrol and Seda ation to Dentistts and Dental Stu udents. This includes a minimum of fourte een (14) hours s of training, i ncluding a clinical compon nent, during w which com mpetency in in nhalation sedation techniqu ue is achieved d. Acceptable ccourses include e those obtaine ed from academ mic programs of instruction reco ognized by the American Dental Association n (ADA) Comm ission on Denttal Accreditation (CODA); OR R courses proved and rec cognized by the e American Dental Association (ADA) Contin nuing Educatio on Recognition Program (CER RP); OR app cou urses approved d and recognize ed by the Acad demy of Genera al Dentistry (AG GD) Program A Approval for Co ontinuing Educcation (PA ACE). __ __ Completion of o an American n Dental Assoc ciation (ADA) Commission C on Dental Accred ditation (CODA) approved or rrecognized pre edoctoral denta al or post-docto oral dental training program which w affords co omprehensive ttraining necesssary to adminisster and ma anage nitrous oxide/oxygen o in nhalation sedation. : See SBDE Rule Stand dard of Care Requirements R R 110.3(b) available a at www w.tsbde.texas.gov.us Clinic cal Requireme ents: See SBD DE Rule 110.3((c) available at www.tsbde.texxas.gov.us EL 1: MINIMAL L SEDATION PERMIT P LEVE Defin nition: A minim mally depressed d level of consciousness prod duced by a pha armacological m method, which retains the pattient’s ability to ind dependently and continuously y maintain an airway and resp pond normally tto tactile stimullation and verb bal command. N Nitrous Oxide may b be used in com mbination with a single enterall drug in minimal sedation. Educ cation and Pro ofessional Req quirements: A den ntist applying fo or a Minimal Se edation: Level 1 Permit must meet ONE of tthe following e educational/professional criterria and subm mit proof of courrse completion: ___ _ Completion of o training to the e level of comp petency in minimal sedation cconsistent with that prescribed d in the Americcan Dental Asssociation (ADA A) Guidelines fo or Teaching Pa ain Control and d Sedation to D Dentists and De ental Students, or a comprehe ensive traiining program in i minimal seda ation that satisfies the require ements describ bed in the Ame rican Dental Asssociation (ADA) Guidelines for Teaching Pain Co ontrol and Seda ation to Dentists and Dental S Students. This s includes a m minimum of six xteen (16) urs of didactic c training and instruction in n which competency in ente eral and/or combined inhala ation-enteral m minimal hou sed dation techniq que is demons strated. ___ _ Completion of o an advanced d education pro ogram accredite ed by the Amerrican Dental Asssociation (ADA A) Commission n on Dental Acccreditation (CO ODA) that afford ds comprehens sive training ne ecessary to adm minister and m anage minimal sedation, com mmensurate with h the ADA’s Gu uidelines for Te eaching Pain Control C and Sed dation to Dentissts and Dental Students. Stand dard of Care Requirements R : See Rule 110 0.4(b) available e at www.tsbde e.texas.gov.us Clinic cal Requireme ents: See Rule e 110.4(c) avaiilable at www.ts sbde.texas.govv Anestthesia Applicattion
Ja anuary 2018
