Please read all items listed below for important information concerning your re-licensure.

Transcription

1 PAUL R. LEPAGE GOVERNOR To: From: All Maine Dental Hygiene (IPDH and RDH) Licensees Maine State Board of Dental Examiners STATE OF MAINE BOARD OF DENTAL EXAMINERS 143 STATE HOUSE STATION AUGUSTA, MAINE DAVID J. MOYER, DDS, MD, PRESIDENT SOUTH PORTLAND GERALDINE A. SCHNEIDER, DMD, VICE PRESIDENT COMPLAINT OFFICER AUBURN DAVID H. PIER, DMD, SEC./TREAS COMPLAINT OFFICER WEST ROCKPORT AUSTIN J. CARBONE, LD WINDHAM NANCY L. FOSTER, RDH, EFDA, EdM HAMPDEN MICHELLE O. GALLANT, RDH ROCKPORT LISA P. HOWARD, DDS KENNEBUNK CHRISTOPHER S. MALLER, DMD BAR HARBOR ROWAN H. MORSE, PUBLIC MEMBER FALMOUTH EXECUTIVE DIRECTOR PENNY VAILLANCOURT Please read all items listed below for important information concerning your re-licensure. 1. The renewal for the dental hygiene license is due January 1, 2015 and must be postmarked by December 31, The current biennium expires December 31, Please complete the application in its entirety. Incomplete applications will be returned. Please type or print legibly and note any address or name change on the application form. 3. If you do not wish to renew, please notify the Board in writing. 4. Application, renewal fee ($140), and continuing education log must be submitted together. Application will not be accepted withou the fee and CE log, or vice-versa. Please remember to sign both documents as well as the check. 5. The CE log must list credits earned between January 1, 2013 and December 31, At least 20 of the required 30 credits must be in category one, and to qualify for category one, must be clinically related. FYI: Hands on courses are not worth double credits in Maine (this includes but is not limited to Yankee Dental Congress courses) please refer to Chapter 13, Item II. B. 2 of the Dental Practice Act. Actual Course Names must be listed, individually, on your CE log. No more than 5 category II credits are allowed per biennium for general attendance at a multi-day convention (you must be in attendance more than 1 day). CPR certification or re-certification is required for renewal of your license (on line courses are not accepted). Three hours of category I credit are allowed per biennium for CPR. You must enclose proof of current CPR certification. 6. We suggest that you attend to renewing your license as soon as possible. If the material you submit has to be returned to you for any reason, it must be returned to this office postmarked no later than the expiration date of December 31, If for some reason, the license is not renewed prior to the expiration date, a late fee ($50) is assessed, over and above the registration fee. However, please be advised that your license will expire on December 31, 2014 and, by law, you are no longer licensed to practice after that date unless an application for renewal is received at the Board office postmarked by that date. If your license is not renewed by January 31, 2015, it must be reinstated. The Board has the authority to grant further extension for the completion of the continuing education requirement upon written request. This request must be submitted prior to the expiration date. 7. The Inactive Status pertains to the Continuing Education requirement only. If one has not earned the required credits, one may apply for the Inactive Status by completing the renewal application, indicating that s/he will not be practicing dental hygiene in Maine during the biennium and submitting with the renewal fee. The certificate will be stamped Inactive. NOTE: Reactivation is not automatic. It will require an interview and may require a refresher course. 8. Please be aware that, by statute, the Board must conduct a random audit of continuing education. Please be sure to keep a copy of your continuing education log and all documentation should you be audited. 9. Chapter 13, section 1 (B) (4) (a, b, c) and (C) (4) (a, b, c) pertains to post-graduate training. Effective 01/01/2011 any hygienist (IPDH or RDH) utilizing this form of continuing education must list not only the name of the program they are enrolled in, but must also list the individual courses taken on their CE log. Only health related courses will be considered for continuing education credit and only those of a clinical nature will be granted category I credits. Health related courses that are not clinically related will be granted category II credits. 10. For those hygienists that hold a Nitrous Oxide Permit, this permit runs concurrently with your hygiene license and is, therefore, renewable at this time. PHONE: (207) FAX: (207) WEBSITE ADDRESS: ADDRESS: dental.board@maine.gov

2 NAME & ADDRESS: State of Maine Board of Dental Examiners 143 SHS -161 Capitol St., Augusta, ME Tel: (207) Application for Biennial Registration Dental Hygiene FOR OFFICE USE ONLY Received Date: Fee: CE: Issue Date: CPR: Registration fee is non-refundable Make check payable to Maine Board of Dental Examiners We also accept Master Card and Visa (please circle type) Card Number: Expiration Date/Sec. Code: Cardholders Name: (Address [City/State] provided above will be listed on the Boards Website) License # Social Security # Phone: (Home/Cell) (Office) Address: Prefer to be contacted at: Home [ ] or at Office [ ] If any information printed above is incorrect, please circle the error and legibly print the correct information. Any change of address or name that is not reported to the Board could be subject to a fine. [ ] I am applying for an initial license to practice dental hygiene in Maine and am enclosing proof of CPR certification. [ ] I am applying for ACTIVE status and am enclosing my CDE log indicating credits earned between January 1 of last year and December 31 of the renewal year and am enclosing proof of CPR certification. [ ] I am applying for ACTIVE status but am not required to list my CDE activities because my license was issued during the year of license renewal. If licensed was issued last year, fifteen (15) credits are required. Proof of CPR is enclosed. [ ] I am applying for Inactive status. I am not practicing Dental Hygiene in the State of Maine at this time, but wish to keep my license current although I have earned no Continuing Education credits. I certify that I will not render any dental hygiene services during the term of this biennium. I understand that my license will be stamped Inactive Status. (Please note: Reactivation is not automatic, it may require an interview and/or refresher course.) Signature Date (Inactive status applicant only) I am currently practicing dental hygiene: [ ] Full time [ ] Part time [ ] Not practicing [ ] Retired [ ] Other - Specify I am practicing as a temporary, either freelance or through Agency. If not currently practicing in Maine, I last practiced in Maine in For Maine employed hygienists only: Employing Dentist (Name & Lic #) Employing Dentist (Name & Lic #) City State Zip City State Zip County Telephone County Telephone Employing Dentist (Name & Lic #) Employing Dentist (Name & Lic #) City State Zip City State Zip County Telephone County Telephone Please list all States/jurisdictions other than Maine in which you currently hold or have ever held a license to practice dental hygiene.

3 PROFESSIONAL HISTORY: Check (X) each appropriate response: Every Yes response must be fully explained by a written statement on a separate sheet of paper. Each explanation must be referenced by the corresponding question number, and must be signed, dated, and enclosed with your registration form. NOTE TO HYGIENIST: PLEASE COMPLETE THIS FORM YOURSELF DO NOT DELEGATE ITS COMPLETION HAVE YOU EVER: 1. Had ANY licensing authority (INCLUDING MAINE) deny your application for any type of license, or take any disciplinary action against the license issued to you in that jurisdiction, including but not limited to warning, reprimand, fine, suspension, revocation, restrictions in permitted practice, or probation with or without monitoring? 2. Been notified of the existence of allegations involving you, filed with or by ANY licensing authority (INCLUDING MAINE), which allegations remain open as of the date of this application? SINCE YOUR LAST RENEWAL APPLICATION: 3. Have you left a dental hygiene licensing jurisdiction (INCLUDING MAINE) while a complaint or allegation was pending? 4. Have you been denied registration or had your ability to prescribe or dispense controlled substances modified, restricted (except by administrative rule or statute in a jurisdiction), suspended, revoked, or voluntarily suspended by N/A a.) U.S. Drug Enforcement Administration (DEA)? b.) Any state/territory of U.S. INCLUDING MAINE? 5. Have you received a sanction from Medicare or from any state Medicaid program? 6. Rendered any dental or dental hygiene services illegally? The purpose of the following questions is to determine the current fitness of the applicant to practice dental hygiene. The following inquiries concern medical, mental health, and addiction issues. This information is treated confidentially by the Board. The mere fact of treatment for medical, mental health or addiction(s) is not, in itself, a basis on which an applicant is ordinarily denied licensure when he/she has demonstrated personal responsibility and maturity in dealing with these issues. The Board encourages applicants who may benefit from such treatment to seek it. The Board may deny a license to applicants whose ability to function in the practice of dental hygiene or whose behavior, judgment, and understanding is impaired by a medical, mental health or addictive condition. SINCE YOUR LAST RENEWAL APPLICATION: 7. Have you been diagnosed with or treated for a medical, mental health, or addictive condition which in any way currently limits or impairs your ability to practice dental hygiene or to function as a dental hygienist? 8. Have you been diagnosed with or treated for any medical, mental health, or addictive disorder that impaired your behavior, judgment, understanding, or ability to function in school, work or other important life activities? 9. Have you had a disabling physical or mental illness(es) that resulted in any hospitalization or that prevented you from working or carrying out your usual daily responsibilities for more than 30 days? 10. Are you now, or since your last renewal have you been dependent upon alcohol or habituating drugs or undergone treatment for such?

4 SINCE YOUR LAST RENEWAL APPLICATION: N/A If any of your answers to questions 7-10 is Yes, are the limitations or impairments caused by your medical, mental health, or addictive condition reduced or improved because you receive ongoing professional treatment (with or without medication) or because you participate in a professional monitoring program? 11. Have you raised the issue of consumption of drugs or alcohol or the issue of a medical, mental health or addictive disorder as a defense or in mitigation of, or as an explanation for your actions in the course of any administrative or judicial proceeding or investigation; any inquiry or other proceeding; or any proposed termination action (educational, employer, government agency, professional organization, or licensing authority)? 12. Are you currently engaged in the illegal use of drugs or misuse of any drugs? 13. Have you been diagnosed with or treated for any type of sexual behavior disorder? SINCE YOUR LAST RENEWAL APPLICATION: 14. Have you been charged, summonsed, indicted, arrested or convicted of any criminal offense, including when those events have been deferred, set aside, dismissed, expunged or issued a stay of execution? Please include motor vehicle offenses but not minor traffic or parking violations. 15. Have you ever had a claim or suit alleging malpractice liability in which you are/were named as a defendant, including nuisance suits settled, adjudicated by a court in favor of the other party, or settled by your insurance company/representatives without your express consent that has not been previously reported to this Board? 16. Are you currently in default on payment of student loans? 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: SSN: The following statement is made pursuant to the Privacy Act of 1974 section 7 (B). Disclosure of your social security number is mandatory. Solicitation of your social security number is solely for tax administration purposes pursuant to 36 MRSA section 175 as authorized by the Tax Reform Act of 1976 (42 USC section-405 (C) (2) (1)). Your social security number will be disclosed to the State Tax Assessor or an authorized agent for use in determining filing obligations and tax liability pursuant to Title 36 of the Maine Revised Statutes. No further use will be made of your social security number and it shall be treated as confidential tax information pursuant to 36 MRSA section 191. 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 and other information listed on this application may be posted on the State s website.

5 BOARD OF DENTAL EXAMINERS 143 State House Station, Augusta, ME TEL: (207) FAX: (207) LOG OF CONTINUING EDUCATION ACTIVITIES FOR THE TWO-YEAR PERIOD PRECEDING THE EXPIRATION DATE OF LICENSE/FIVE-YEAR PERIOD PRECEDING THE EXPIRATION DATE OF EFDA CERTIFICATION. This form must be completed, signed and returned with your completed renewal application and fee. CATEGORY 1: CDE activities with accredited sponsorship. Must be clinically related. At least 40 credits for Expanded Function Dental Assistants, 30 credits for Dentists, 20 for Hygienists (IPDH and RDH), and 15 for Denturists must be earned in this category. The total 50 for EFDA s, 40 for Dentists, 30 for Hygienists (IPDH and RDH), and 20 for Denturists - may be earned in this category. Continuing Education Credits are awarded on the basis of one credit per hour of participation; hands on courses are not worth double credits in Maine-see Ch. 13, Item II.B.2. of the Dental Practice Act. Clinically applied home study courses that include an examination will be accepted for category 1 credit, up to 10 credits for dentists, dental hygienists, and EFDA s and 5 credits for denturists per biennium. CATEGORY 2: CDE activities with non-accredited sponsorship. You can claim no more than 5 credits, per biennium, for multi-day attendance at a multi-day convention toward the renewal of your license. Home study or correspondence courses with self-assessment tests are also category 2 (unless clinically applied, see above). Courses that are not directly related to clinical practice would be category 2. Name: Address: Maine License #: Computer printout or format similar to that below (designate Cat 1/Cat 2; list course names) will be accepted if signed. CPR certification or re-certification is required for all new EFDA Certifications; Dental, Dental Hygiene (IPDH & RDH), Denturist, and Radiography licensees, as well as the renewal of those same certifications/licenses. On-line CPR is not accepted; three hours of category I credit are allowed per biennium. Enclose proof of current CPR. Unless renewal materials are received at the Board office, postmarked by December 31 st, you cannot legally practice after that date. DENTISTS: Dentists may claim up to a maximum of twenty (20) hours CDE per year when they are or have been enrolled in a CODA-approved post-graduate program of at least six months duration for the year in which the CDE is being claimed. On this log, list the name of the program and the names of the individual courses taken. Only health related courses will be considered for continuing education credit and only those of a clinical nature will be granted category 1 credits. Health related courses that are not clinically related will be granted category 2 credits. Please see the Board s Policy List, available at for further clarification. HYGIENISTS: Each full year of completed post-graduate training in one of the following programs (related Dental, Medical or Dental Hygiene Degree Program) will be considered the equivalent of the annual CDE requirements of 15 credits for a hygienist (IPDH and RDH). Please see the Board s Policy List, available at for further clarification. List the name of the program and the names of the individual courses taken. Only health related courses will be considered for continuing education credit and only those of a clinical nature will be granted category I credits. Health related courses that are not clinically related will be granted category II credits. Your signature is required on this document I certify the following to be true and correct. Failure to sign this document will result in delays in the processing of your renewal application (MUST BE PRINTED OR TYPED) Signature: ACCREDITED SPONSOR CDE Programs LOCATION OF ACTIVITY CITY, STATE ACTIVITY NAME AND DESCRIPTION OF ACTIVITY (COURSE NAME, PAPER, JOURNAL, ETC) DATES OF ATTENDANCE CREDITS Cat 1 Cat II

6 (MUST BE PRINTED OR TYPED) ACCREDITED SPONSOR CDE PROGRAMS LOCATION OF ACTIVITY CITY, STATE ACTIVITY NAME AND DESCRIPTION OF ACTIVITY (COURSE NAME, PAPER, JOURNAL, ETC.) DATES OF ATTENDANCE Total CE Credits CREDITS Cat 1 Cat II