INSTRUCTIONS. Please see Board Rules Chapter 14: RULES FOR USE OF SEDATION AND GENERAL ANESTHESIA BY DENTISTS for further explanation.

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1 INSTRUCTIONS To Moderate Sedation Applicant: Enclosed please find an application from the Maine Board of Dental Examiners regarding the administration of moderate sedation. No dentist shall be required to obtain a permit in order to administer minimal sedation as defined by the ADA Guidelines, however, dentists who administer minimal sedation to patients age 12 and under require a permit for moderate sedation. Please see Board Rules Chapter 14: RULES FOR USE OF SEDATION AND GENERAL ANESTHESIA BY DENTISTS for further explanation. Types of Permits: Permit A: Moderate Sedation Level I (Enteral): No dentists shall employ or use moderate sedation as defined by the ADA Guidelines on an outpatient basis for dental patients, unless such dentist possesses a Permit for Moderate Sedation issued by the Maine Board of Dental Examiners. Permit B: Moderate Sedation Level II (Parenteral): A dentist issued a Permit for Moderate Sedation Level II (Parenteral) by the Board may also perform Moderate Sedation Level I (Enteral) and Minimal Sedation. A dentist issued a Permit for Deep Sedation/General Anesthesia by the Board may also perform any type of moderate or minimal sedation. Upon Board approval of the application, you may be issued a temporary permit as outlined in Section III (C) (5c) of the regulation. This permit will remain in effect six (6) months at which time the Board will vote to approve or disapprove a permanent five-year permit after an on-site inspection. Temporary permits are nonrenewable and may not exceed six (6) months duration. This application should only be submitted after determining that all the requirements of this regulation have been met. Complete all sections of this application and submit it to the Board of Dental Examiners along with the non-refundable application fee of $400. No application will be processed without the application fee. PRIVACY: Notice regarding Public Information This application is a public record for purposes of Maine s Freedom of Access Law, 1 MRSA 401, et seq. Public records must be made available to any person upon request. Information that you supply as part of this application (except your Social Security number and credit card number) is public information. Other licensing records to which this information may later be transferred are also considered public records. Where permitted by law, your name, license number, mailing address ad other information listed on this application may be posted on the State s website. Please complete and return to this office pages 2 and 3 of application form along with the appropriate permit A or permit B form.

2 APPLICATION FOR PERMIT TO ADMINISTER MODERATE SEDATION PLEASE ANSWER ALL QUESTIONS:,, ( ) ( ) Last Name First Name MI Home Phone Office Phone,,, Number and Street Town State Zip Code I am applying for this permit: Circle One a. In conjunction with my application for licensure as a dentist b. As a Maine licensed dentist #. Have you been convicted of a crime (felony or misdemeanor) in any state or country? Have you ever been charged with a crime (felony or misdemeanor) in any state or country, the disposition of which was other than by acquittal or dismissal? Have you ever surrendered your license or been found guilty of professional misconduct, unprofessional conduct, incompetence or negligence in any state or country? Are charges pending against you for professional misconduct, unprofessional conduct, incompetence or negligence in any state or country? Has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition of such measures? Has your Drug Enforcement Agency or other controlled substance authorization been denied, revoked, suspended, or reduced, or have proceedings toward these ends been instituted? Have any judgements been taken against you or medical malpractice awards rendered against you arising out of a claim of malpractice in any jurisdiction related to your use of moderate sedation? Have you been or are you now addicted to the use of drugs or alcohol? - 2 -

3 Have any settlements been made by you or on your behalf by an insurance carrier arising out of a claim of malpractice related to your use of moderate sedation? Are there any malpractice claims currently pending against you in any court or have you received notice that any patient is presently considering bringing a malpractice claim against you related to your use of moderate sedation? Are you currently in default on payment of student loans? Circle One If the answer to any of these questions is Yes, submit a letter giving a complete explanation, include any court records, and if you possess one, a copy of the Certificate of Relief from Disabilities or your Certificate of Good Conduct. I possess a current certification in: (a) Basic Life Support for Healthcare Providers (BCLS); and (b) Advanced Cardiac Life Support (ACLS) or an appropriate dental sedation/anesthesia emergency management course (If yes, attach documentation) Notice: Unless all pertinent information requested is answered, this application will be returned to the licensee. I swear or affirm under penalties of perjury and false swearing and subject to the disciplinary laws and rules of the Board that all information requested in this registration form has been answered, and that all answers are accurate and truthful. Date: Signed: Type or print: - 3 -

4 PERMIT A Permit for Moderate Sedation Level I (Enteral) ( ) I have attached documentation of successful completion of pre-doctoral or continuing education moderate sedation training in an accredited educational institution or program, which included a minimum of twenty four hours of didactic instruction and ten cases of clinical experience as set forth in Section III (C) (5a.) of the rules regarding the use of moderate sedation OR a Board-approved comprehensive training program. Additional supervised clinical experience is necessary to prepare participants to manage medically compromised adults and special needs patients. List the practice location(s) at which moderate sedation level I (enteral) will be administered: A separate fee is required for each facility permit applied for. This is to cover the cost of the Anesthesia Evaluation Committee On-Site Inspection. I HEREBY CERTIFY, UNDER THE PAINS AND PENALTY OF PERJURY, THAT I HAVE A PROPERLY EQUIPPED FACILITY AND A PROPERLY TRAINED STAFF UNDER CHAPTER 14 OF THE RULES OF THE BOARD OF DENTAL EXAMINERS AND FURTHER, THAT THE INFORMATION PROVIDED HEREIN IS TRUTHFUL. Date Signature of Applicant - 4 -

5 PERMIT B Permit for Moderate Sedation Level II (Parenteral) ( ) I have attached documentation of successful completion of pre-doctoral or continuing education moderate sedation training in an accredited educational institution or program, which included a minimum of sixty hours of didactic instruction and twenty cases of clinical experience as set forth in Section III (C) (5b.) of the rules regarding the use of moderate sedation OR a Board-approved comprehensive training program. List the practice location(s) at which moderate sedation level II (parenteral) will be administered: A separate fee is required for each facility permit applied for. This is to cover the cost of the Anesthesia Evaluation Committee On-Site Inspection. I HEREBY CERTIFY, UNDER THE PAINS AND PENALTY OF PERJURY, THAT I HAVE A PROPERLY EQUIPPED FACILITY AND A PROPERLY TRAINED STAFF UNDER CHAPTER 14 OF THE RULES OF THE BOARD OF DENTAL EXAMINERS AND FURTHER, THAT THE INFORMATION PROVIDED HEREIN IS TRUTHFUL. Date Signature of Applicant - 5 -

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