Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350, Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7764 www.dora.colorado.gov/professions
Reinstatement Application to Administer MINIMAL SEDATION, MODERATE SEDATION, OR DEEP SEDATION/GENERAL ANESTHESIA—DENTIST MINIMAL - $49 MODERATE - $148 DEEP/GENERAL -$148 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado.
APPLICANT INSTRUCTIONS Reinstatement of Anesthesia Permit Required. Pursuant to section 12-35-140, C.R.S., an anesthesia or sedation permit issued to a licensed dentist is valid for five years, unless the dentist’s license expires. Board Rule XIV requires that a dentist maintain an active permit in order to administer anesthesia in Colorado, including successfully renewing it every five years. If a permit is not renewed within that timeframe, it will expire and a reinstatement application must be filed, approved, and a reinstated permit issued in order to resume administering anesthesia in the state of Colorado. Submission of this application does not guarantee reinstatement of your permit. Plan ahead for the time it will take for us to receive all required documents and complete our evaluation. Basic Requirements. All applicants must hold an active Colorado dentist license. Other requirements are outlined in section 12-35-140, C.R.S., of the Dental Practice Act, and Board Rule XIV. Both documents are available online at: www.colorado.gov/dora/Dental_Board.
All Colorado licensed dentists with an active status shall be authorized to administer local anesthesia, analgesia, medication prescribed/administered for the relief of anxiety or apprehension, and nitrous oxide/oxygen inhalation analgesia by virtue of their license in compliance with section E of Board Rule XIV. If you do not intend to administer general anesthesia, deep sedation, moderate sedation or minimal sedation, you do not need to complete this application
Inspection
Any dentist applying to reinstate a Moderate Sedation Permit or a Deep Sedation/General Anesthesia Permit must submit an updated clinical on-site inspection as required pursuant to section 12-35-140(5), C.R.S. In order to do so, he/she must first be approved for an Inspection Permit before proceeding with a clinical on-site inspection. The Inspection Permit may only be utilized for purposes of undergoing the Board-approved clinical on-site inspection. A dentist applying to reinstate a Minimal Sedation Permit is NOT required to complete a clinical on-site inspection. The inspector shall be a Board-approved Colorado licensed physician or certified registered nurse anesthetist (CRNA) trained in dental outpatient deep sedation/general anesthesia and moderate sedation, or a dentist issued a Deep Sedation/General Anesthesia Permit pursuant to section 12-35-140(5)(a), C.R.S. The inspector cannot have a vested interest in the outcome of the inspection; therefore, the inspector retained cannot have a business or familial relationship and must be able to maintain complete impartiality. Any dentist applying to reinstate his/her Moderate Sedation or Deep Sedation/General Anesthesia permit is required to submit the anesthesia record(s) for the case(s) performed during the clinical on-site inspection along with the completed Inspector Report Form. Any anesthesia record submitted must be in compliance with the documentation requirements of Rule XIV(O) in order to be acceptable.
Life Support Certifications
Any dentist applying to reinstate a permit is required to have successfully completed and maintain continuous certification of Basic Life Support (BLS) training for health care providers that meets the requirements of Rule III(G)(7). Successful completion of Pediatric Advanced Life Support (PALS) training and continuous certification is required for a dentist that applies for and/or maintains a Pediatric Designation on his/her permit in order to administer to patients under 12 years of age. For Moderate Sedation or Deep Sedation/General Anesthesia permit holders only—to reinstate an active permit, and in addition to BLS training, a license must also have successfully completed current Advanced Cardiac Life Support (ACLS) in order to administer to patients 12 years and older, and maintain continuous certification. It is the dentist’s responsibility to maintain current BLS and ACLS and/or PALS certification at all times.
Continuing Education Credits
A dentist reinstating his/her permit is required to complete at least 17 hours of Board-approved continuing education credits specific to anesthesia or sedation administration during the five-year period prior to submitting the
Applicant: Keep this page for your records.
07/2016
Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350, Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7764 www.dora.colorado.gov/professions
Reinstatement Application to Administer MINIMAL SEDATION, MODERATE SEDATION, OR DEEP SEDATION/GENERAL ANESTHESIA—DENTIST MINIMAL - $49 MODERATE - $148 DEEP/GENERAL -$148 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado.
reinstatement application. Board-approved credits are those meeting the requirements of Rule XIV(R)(5)(c). Time spent maintaining current BLS, ACLS, and/or PALS may NOT be applied towards this requirement. Current Competency
If a dentist has not had an active permit within the two years immediately preceding the application for reinstatement, he/she is required to demonstrate at least one of the following: o
Submit proof satisfactory to the Board that he/she has engaged in the level of administration of anesthesia within generally accepted standards of dental practice and in compliance with sections O and P of Rule XIV at or above the level for which he/she is applying for at least one of the five years immediately preceding the application; or
o
Submit proof satisfactory to the Board of an evaluation, completed within one year preceding the application by a person or entity approved by the Board that certifies the applicant’s ability to administer anesthesia within generally accepted standards of dental practice and in compliance with sections O and P of Rule XIV at or above the level for which he/she is applying. The proposed procedure for the evaluation and the proposed evaluating person or entity must be submitted for pre-approval by the Board.
About the Application. This application is to be completed by you and submitted to the Colorado Dental Board. All questions on the application are mandatory, and all supporting documents must be received before the application may be considered. The application forms must be completed in original ink or typed. Keep a copy of the completed application and supporting documents for your records. Application Expiration. Your application will be kept on file for one year from the date of receipt in the Division. Your file and all supporting documentation will be purged if you do not submit required documents and complete your application process in one year. You will need to submit a new application packet after that time. Social Security Number is Required. Effective January 1, 2009, a Social Security Number is required for all licensees. The Division will consider an application to be incomplete when the applicant fails to submit their Social Security Number. Exceptions are made for foreign nationals not physically present in the United States and for non-immigrants in the United States on student visas who do not have a Social Security Number. These applicants must submit a signed Social Security Number Affidavit in lieu of a Social Security Number available online at: www.colorado.gov/dora/DPO_Update_Contact. Disclosure of Addresses. Consistent with Colorado law, all addresses and phone numbers on record with the Division are public record and must be provided to the public when requested. It is your responsibility to keep your contact information current in our system. Your email address is not open to public record, but must be provided on this application. Any requests for additional information, license/permit information and renewal notices will be emailed to the email address on record. If your email address is not current, it is possible you will not receive important information from the Division. You can change your contact information online by using Online Services at: www.colorado.gov/dora/licensing. Checking Your Application Status. Visit Online Services at: www.colorado.gov/dora/licensing to track your application from the date we log it in our database to the date your permit is emailed to you as a PDF for printing. Please allow us enough time to receive the application through the mail and enter your application into our database before you check the website. We recommend waiting at least 10 business days from date of mailing before checking the status of your application.
Applicant: Keep this page for your records.
07/2016
Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350, Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7764 www.dora.colorado.gov/professions
Reinstatement Application to Administer MINIMAL SEDATION, MODERATE SEDATION, OR DEEP SEDATION/GENERAL ANESTHESIA—DENTIST MINIMAL - $49 MODERATE - $148 DEEP/GENERAL -$148 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado.
APPLICANT CHECKLIST All Applicants: To reinstate a permit to administer minimal sedation, moderate sedation, or deep sedation/general anesthesia: Complete the attached application. Submit the completed application and all supporting documentation to the Colorado Dental Board, including the appropriate fee. All fees are non-refundable and subject to change every July 1st. Provide documentation of any name change. If your name has changed since you obtained a previously-issued license, or if your name is different on any of your supporting documentation, you must provide a copy of the legal document verifying the name change (i.e., marriage license, divorce decree, or court order). Submit proof of life support certification. Submit proof of current Basic Life Support certification (BLS) for healthcare providers that meet the requirements of Rule III(G)(7). Also, successful completion of Pediatric Advanced Life Support (PALS) training and continuous certification is required for a dentist that applies for and/or maintains a Pediatric Designation on his/her permit; administering to patients under 12 years of age. Any dentist applying for a Moderate Sedation Permit or a Deep Sedation/General Anesthesia Permit must submit proof of current Advanced Cardiac Life Support (ACLS) certification if administering to patients 12 years and older. It is the dentist’s responsibility to maintain current BLS and ACLS and/or PALS certification at all times. Continuing education certificates of completion. Complete the “Anesthesia/Sedation Administration Continuing Education Record” and submit it along with a copy of each certificate of completion for every course completed as part of the 17 hours of continuing education in anesthesia or sedation administration required to reinstate an anesthesia permit. Current competency. Submit proof of competency if your permit has been expired for more than two years by either demonstrating acceptable engagement in the administration of anesthesia or completing a Board approved evaluation.
If you are reinstating a Moderate Sedation Permit or a Deep Sedation/General Anesthesia Permit (not required for renewing a Minimal Sedation Permit, unless a “Yes” response is provided to any of the screening questions, which then means your application must be reviewed by the Board): Review the Anesthesia Application Consultant Committee and the Board’s meeting schedule at: www.colorado.gov/dora/Dental_Board and click on “Calendar/Events” under the “Program Information” section of the main page for agenda cutoff deadlines and meeting dates, times, and locations for when your application may be considered since your application must be reviewed by both the Committee and the Board due to your clinical on-site inspection requirement. Note: Applications will first be reviewed by the Committee and its recommendation will be reviewed by the assigned Board panel at its next scheduled meeting. Panel B is currently reviewing anesthesia applications. Panel A will review anesthesia applications January 1st through December 31st of the calendar year 2017 and Panel B will review them for the following calendar year in 2018. The review schedule will alternate accordingly in subsequent calendar years. Wait to be issued an Inspection Permit by the Colorado Dental Board before arranging for an anesthesia inspection in compliance with Rule XIV(L). This permit is not authorization to administer anesthesia, unless it is limited to anesthesia administered as part of your required inspection. Provide the applicable Inspector Report Form (available at www.colorado.gov/dora/Dental_Board, click on “Find Applications & Forms” under the “Licensing Services” section of the main page) and a copy of Board Rule XIV to the Inspector. The Inspector must return the completed Inspector Report Form directly to the Board (please feel free to keep a copy for yourself in case it is required by another organization, i.e. your specialty society for purposes of certification or re-certification with them) along with a copy of the complete anesthesia record for each case observed. A submitted anesthesia record must be in compliance with the documentation requirements of Rule XIV(O). Submit the completed application below and all supporting documentation to: Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 Applicant: Keep this page for your records.
07/2016
Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350, Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7764 www.dora.colorado.gov/professions
Reinstatement Application to Administer MINIMAL SEDATION, MODERATE SEDATION, OR DEEP SEDATION/GENERAL ANESTHESIA—DENTIST MINIMAL - $49 MODERATE - $148 DEEP/GENERAL -$148 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado.
The content of this application must not be changed. If the content is changed, the applicant may be referred to the Colorado State Attorney General’s Office for violation of Colorado law. Colorado Dentist License Number:
Expiration Date:
Permit type for which you are reinstating (check only one): Minimal Sedation Permit Moderate Sedation Permit Deep Sedation/General Anesthesia Permit
Reinstating a Pediatric Designation: YES NO Required to have been previously issued PALS required if “Yes” is checked
PART 1—APPLICANT INFORMATION Name: First:
Middle:
Last:
Suffix:
Previous Name(s): Social Security Number: * E-mail Address: (This will be the primary communication method) Mailing Address: This is a
Home
PO Box, Street: Business
Daytime Telephone Number: (
City, State, Zip: )
Date of Birth (mm/dd/yyyy):
PART 2—LIFE SUPPORT CERTIFICATIONS List below and submit proof of current Basic Life Support (BLS) certification for healthcare providers that meet the requirements of Rule III(G)(7), and Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) certification as appropriate. It is the dentist’s responsibility to maintain current BLS and ACLS and/or PALS certification at all times. BLS certification issue or renewal date: —AND—
Expiration date:
ACLS certification issue or renewal date: _______ —AND/OR— PALS certification issue or renewal date:________________________________
Expiration date: Expiration Date: ______________________
* Social Security Number Disclosure: Section 24-34-107(1) of the Colorado Revised Statutes requires that every application by an individual for a license issued pursuant to the authority set forth in title 12, C.R.S., by the Department of Regulatory Agencies, shall require the applicant's social security number. Disclosure of your social security number is mandatory for purposes of establishing, modifying, or enforcing child support under § 14-14-113 and § 26-13-126, C.R.S.; locating an individual who is under an obligation to pay child support as required by § 26-13-107(3)(a)(I)(A), C.R.S.; and reporting to the Health Integrity and Protection Data Bank as required by 45 CFR §§ 61.1 et seq. Failure to provide your social security number for these mandatory purposes will result in the denial of your licensure application. Disclosure of your social security number is voluntary for disclosure to other state regulatory agencies, testing and examination vendors, law enforcement agencies, and other private federations and associations involved in professional regulation for identification purposes only. Your social security number will not be released for any other purpose not provided for by law.
OFFICE USE ONLY
DATE APPROVED: ____________________________
Reinstatement Permit—Dentist
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DATE ISSUED: _________________________________ 07/2016
APPLICANT NAME:
PART 3—SCREENING QUESTIONS Provide the following for each YES response to screening questions 1 through 3: • A personally written explanation; • A copy of the formal complaint/pleading; • The answer to the complaint for malpractice issues; • A copy of the final outcome(s) and/or a report of status if judgment is pending; • Proof of compliance if under criminal probation; • A copy of investigative report/complaint; and • Any further information requested by the Board in a separate communication. 1. Has your license to practice dentistry been suspended, revoked, or otherwise disciplined in any state or territory of the United States, or in any foreign country related to an anesthesia/analgesia incident since you were last privileged or permitted in Colorado to administer anesthesia?
YES
NO
2. Have you had any malpractice judgment, malpractice settlement, or governmental/private agency disciplinary action against you since you were last privileged or permitted in Colorado to administer anesthesia or is such an action currently pending against you?
YES
NO
3. Have you ever had any criminal conviction, deferred judgment or plea of nolo contendere entered against you since you were last privileged or permitted in Colorado to administer anesthesia or is there any criminal charge or investigation currently pending against you? This includes, but is not limited to, any judgments/charges related to sales, distribution, possession, manufacture or dispensation of any controlled or illegal substance.
YES
NO
Provide the following for each YES response to screening questions 4 through 6: • A personally written explanation. For questions 4 and 5, also give: • • • •
Dates of onset; Description of treatment; Name and address of treating physician; and Your description of the current status of your condition. You may wish to submit a physician’s report of the current status of your condition and any limitations which may affect your ability to safely practice dentistry.
4. Do you now abuse or excessively use, or have you in the last five years abused or excessively used, any habit forming drug, including alcohol, or any controlled substance that has a) resulted in any accusation or discipline for misconduct, unreliability, neglect of work, or failure to meet professional responsibilities; or b) affected your ability to practice as a dentist safely and competently?
YES
NO
5. In the last five years, have you been diagnosed with or treated for a condition that significantly disturbs your cognition, behavior, or motor function, and that may impair your ability to practice as a dentist safely and competently including but not limited to bipolar disorder, severe major depression, schizophrenia or other major psychotic disorder, a neurological illness, or sleep disorder?
YES
NO
6. Are there any other facts concerning your background history, experience, or activities since you were last privileged or permitted in Colorado to administer anesthesia which may have a bearing on your fitness to practice dentistry in Colorado and which should be brought to the attention of the Colorado Dental Board?
YES
NO
Reinstatement Permit—Dentist
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APPLICANT NAME:
ATTESTATION I hereby certify that I have met ALL the requirements for administering anesthesia in the state of Colorado pursuant to section 12-35-140, C.R.S., and Board Rule XIV under the following permit type (check one): Minimal Sedation Permit Moderate Sedation Permit Deep Sedation/General Anesthesia Permit I hereby certify that I have met the requirements to administer anesthesia to patients under 12 years of age in the state of Colorado pursuant to section 12-35-140, C.R.S., and Board Rule XIV (check if applicable): Pediatric Designation I attest that I am in full compliance with all the requirements in Board Rule XIV, including the required office facilities and equipment pursuant to section (M). Furthermore, I attest that an end-tidal carbon dioxide monitor is also included with the required office facilities and equipment if moderate sedation or deep sedation/general anesthesia is being administered in my dental office or if I am administering moderate sedation or deep sedation/general anesthesia in the office of another dentist. I further attest that I will maintain current Basic Life Support (BLS) certification and an Advanced Cardiac Life Support (ACLS) and/or Pediatric Life Support (PALS) certification as long as I am administering anesthesia in the state of Colorado. I further attest that I have submitted during the times I was privileged/permitted to administer anesthesia in Colorado and/or will submit upon reinstatement of this permit to the Colorado Dental Board an anesthesia morbidity/mortality report within 15 days of any anesthesia related incident resulting in morbidity to the patient requiring hospital admission or patient mortality in compliance with Rule XIV(S), if applicable. I state under penalty of perjury in the second degree, as defined in section 18-8-503, C.R.S., that the information contained in this application is true and correct to the best of my knowledge. In accordance with section 18-8501(2)(a)(I), C.R.S., false statements made herein are punishable by law and may constitute a violation of the Dental Practice Act.
Applicant Signature
Date
ANESTHESIA/SEDATION ADMINISTRATION Reinstatement Permit—Dentist
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APPLICANT NAME:
CONTINUING EDUCATION RECORD
Applicant: A dentist reinstating his/her permit is required to complete at least 17 hours of Board-approved continuing education credits specific to anesthesia or sedation administration during the five-year permit period prior to applying for reinstatement of his/her permit. In order to be eligible for reinstatement, complete this form and certify that you have completed the required 17 hours of continuing education specific to anesthesia or sedation administration during the five years immediately preceding this application. Submit this form and copies of your certificates of completion with this application.
Note: Time spent to maintain current BLS, ACLS, and/or PALS will not apply towards this requirement. Board approved continuing education credits in anesthesia or sedation administrative are limited to any course or program recognized by the (or successor organization): o American Dental Association (ADA) Continuing Education Recognition Program (CERP); o Academy of General Dentistry (AGD) Program Approval for Continuing Education (PACE); o American Medical Association (AMA); or o Commission on Dental Accreditation (CODA) accredited institute.
The information you provide below is subject to verification. You may be required to provide additional information.
Course Title / Sponsor
Location
Instructor
Dates
Hours
TOTAL I hereby attest that the above is a true and accurate accounting of the continuing education I have completed.
SIGNATURE
Reinstatement Permit—Dentist
DATE
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