Will This Work s5

New Mexico Regulation and Licensing Department BOARDS AND COMMISSIONS DIVISION New Mexico Board of Dental Health Care and New Mexico Dental Hygienist Committee Toney Anaya Building ▪ 2550 Cerrillos Road ▪ Santa Fe, New Mexico 87505 (505) 476-4680 ▪ Fax (505) 476-4545 ▪ www.RLD.state.nm.us/boards/dental_health_care.aspx

TO: Dental Hygiene Applicants for Collaborative Practice

FROM: New Mexico Dental Health Care, Board Administrator

*All licensing information provided is public information*

Thank you for your interest in certification as a Collaborative Practice Dental Hygienist in the State of New Mexico. Enclosed are the current application and a copy of the rules related to "Collaborative Practice", a protocol form template, and a patient release template.

It is important you complete each area on the application form and submit the required fee.

The following information is required as part of your New Mexico Dental Hygiene Committee- Application for Certification for the Collaborative Practice of Dental Hygiene. Applications are valid for one year from the date of receipt by the Board office.

 Completed New Mexico Dental Hygiene Committee Application for Certification for the Collaborative Practice of Dental Hygiene, signed and notarized with the application fee of $150 payable to the New Mexico Board of Dental Health Care. (Application fees are non-refundable). The application fee includes the initial licensing period, not to exceed three years  Possess a current New Mexico dental hygiene license in good standing.  Have been engaged in the active practice of dental hygiene as defined in 61-5A-4(B) of the Act for not less than:

2400 hours of active practice for the past eighteen months; OR A total of 3,000 hours of active practice and has been engaged in active practice for two of the past three years.

 Meet the educational criteria for licensure in Section 61-5A-13 (A) of the Act.

 Have 15 hours of continuing education in clinical dental hygiene in the twelve (12) months prior to certification, which includes courses in infection control and medical emergencies.

Revision date: 02/2012 Page 1 of 13 Documentation Requirements: (Please use this as a checklist for your application)

_____ Verification of a current active DH license; (copy)

_____ Proof of the active practice of dental hygiene as defined in paragraph (2) Subsection A of 16.5.17.8 NMAC of this Part. This proof may be in the form of notarized letters from employers, supervisors of dental clinics of one of the Uniformed Services of the United States, or faculty administrators of accredited schools. If this documentation cannot be obtained, the applicant may request to provide other proof of the required hours to the Committee for consideration;

_____ Copy of current Basic Life Support (BLS) or Cardiac Pulmonary Resuscitation (CPR) certification accepted by the American Heart Association, American Red Cross or the American Safety Health Institute; cannot be a self-study course;

_____ Copies of 15 hours of continuing education related to the clinical practice of dental hygiene; (Must include courses in infection control and medical emergencies)

_____ A copy of a signed collaborative practice agreement between a dental hygienist and a consulting dentist.

_____ A signed copy by the dentists and dental hygienist of the collaborative practice protocols.

Upon completion of your application, receipt of all required fees, all documentation, and approval by the Committee and the Board (or its designees), you will be sent verification of your certification. The average application takes 4- 6 weeks to process. Please keep the Board informed of any address changes in writing. Any questions please contact the Board office at (505) 476-4680, by fax at (505) 476-4545 or by e-mail [email protected].

New Mexico Regulation and Licensing Department BOARDS AND COMMISSION DIVISION Revision date: 02/2012 Page 2 of 13 New Mexico Regulation and Licensing Department BOARDS AND COMMISSIONS DIVISION New Mexico Board of Dental Health Care and New Mexico Dental Hygienist Committee Toney Anaya Building ▪ 2550 Cerrillos Road ▪ Santa Fe, New Mexico 87505 (505) 476-4680 ▪ Fax (505) 476-4545 ▪ www.RLD.state.nm.us/boards/dental_health_care.aspx

APPLICATION FOR CERTIFICATION FOR THE COLLABORATIVE PRACTICE OF DENTAL HYGIENE

*All licensing information provided is public information*

(Application fees are non-refundable)

Certification FEE $150

1. PERSONAL INFORMATION

Last Name ______First ______Middle ______

Mailing Address: ______

City: ______State: ______Zip: ______

Contact Phone: (_____) ______E-Mail address: ______

Business Mailing Address: ______

City: ______State: ______Zip: ______

Contact Phone Number: ( ) Business Phone: (____) ______

______-______-______Date of Birth Place of Birth Social Security Number

Proposed Practice Name: ______

Proposed Address: ______

2. LICENSURE INFORMATION Do you have a New Mexico License? YES ______NO ______

If yes, what was your license number? ______Issue date: ______Expiration date: ______

List all states (or countries) in which you are or have been licensed, regardless of current status (Attach additional pages if necessary): State/Country Licensed by exam/ License Issue License Expiration credentials Number Date Status Date

Revision date: 02/2012 Page 3 of 13 PROOF OF ACTIVE PRACTICE OF DENTAL HYGIENE: Attach pay stubs for the hours claimed or notarized affidavits from employers, supervisors, or faculty administrators attesting to the hours claimed.

List all employment and the number of hours of active hygiene practice for the past three (3) years.

Dates City & State of residence Occupation Hours of Active Practice

PROOF OF CONTINUING EDUCATION: Attach all continuing education in clinical dental hygiene in the previous 12 months.

DatesCourse(s) Location Hours Earned

Infection Control Course: Attach a copy of course certificate.

______(Title) (Date) (Location)

PROOF OF MEDICAL EMERGENCIES COURSE: Attach a copy of course certificate.

______(Title) (Date) (Location)

PROOF OF CURRENT BASIC LIFE SUPPORT OR CARDIAC PULMONARY RESUSCITATION (CPR): Attach a copy of course certificate. (cannot be a self-study course) ______(Title) (Date) (Location)

PROOF OF COLLABORATIVE PRACTICE AGREEMENT: Attach photocopy of a signed collaborative agreement with a consulting dentist(s).

PROOF OF COLLABORATIVE PRACTICE SCOPE OF PRACTICE: Attach photocopy of signed collaborative practice protocol(s) with each consulting dentist(s).

PATIENT RELEASE FORM: Attach photocopy of an example of a patient release form (with appropriate disclaimer) to be used by the collaborative practice.

New Mexico Regulation and Licensing Department BOARDS AND COMMISSION DIVISION Revision date: 02/2012 Page 4 of 13 PROPOSED COLLABORATIVE PRACTICE SETTING: Please complete the following: Private Collaborative Hygiene Practice: ______Community-Based Collaborative Hygiene Practice: ______Proposed Practice Address: ______

City: ______State: ______Zip: ______

3. PLEASE ANSWER THE FOLLOWING QUESTIONS: GIVE DETAILS OF ANY "YES" ANSWERS ON A SEPARATE SHEET OF PAPER

A. Have you ever used another name under which records relating to your application, education, training or experience may be filed? YES ______NO ______

If yes, please enter name(s) used: ______

B. Have you ever received a deferred prosecution or judgment or been convicted of, or pled guilty or nolo contendere to a felony or misdemeanor (not including traffic violations) in any state, territory or district of the United States or a foreign country? YES _____ NO _____

C. Have you ever had any disciplinary action taken against your dental hygiene license or any other professional license in any state? (NOTE: Disciplinary action includes, but is not limited to, suspension, probation, practice limitations, reprimand, letter or admonition, censure, and any allegations currently pending.) YES ______NO ______

D. Have you ever been a defendant in a legal action involving professional liability (malpractice), or had a professional liability claim paid in your behalf, or paid such a claim yourself? YES ______NO ______

E. Have you ever voluntarily surrendered a license or certification to practice dental hygiene or any other health related profession in any state, foreign country, territory, or institution? YES ______NO ______

F. Are you currently more than thirty days in arrears in payment of amounts required to be paid pursuant to an outstanding judgment and order for child support in New Mexico or any other state? YES ______NO ______

G. Do you have a medical condition which in any way impairs or limits your ability to practice dental hygiene with reasonable skill and safety? YES ______NO ______

H. Do you now or have you ever had a chemical substance(s) abuse problem? YES ______NO ______

I. Are you currently engaged in the illegal use of controlled dangerous substances? YES ______NO ______

J. Are you currently participating in a supervised rehabilitation program or professional assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances? YES ______NO ______

New Mexico Regulation and Licensing Department BOARDS AND COMMISSION DIVISION Revision date: 02/2012 Page 5 of 13 I HEREBY CERTIFY that I am the person described and identified in this application; this application contains no willful misrepresentation; and the information given by me is true and complete to the best of my knowledge and belief.

I further certify I have read the New Mexico Dental Health Care Act and Rules and fully understand that I bind myself to be governed by them.

______Signature of Applicant Date

STATE OF ______

COUNTY OF ______

BEFORE ME on this ______day of ______, 2____, personally appeared the above-named applicant who, being by my duly sworn upon oath, states that all statements and answers contained in this application are true and correct.

______Notary Public Seal My Commission Expires: ______

All requested information is essential and must be provided. Failure to present a completed application by omitting information sought, having less than a full and complete disclosure, or failure to have the required documentation provided as required in this application, will result in delay or cause return of the application. The board shall neither approve nor deny an application until it is received in proper form, contains the information required by law and as requested by this application. The responsibility for completing the application is solely that of the applicant. The burden of proof in satisfying the Board that you are entitled to a license as a Collaborative Dental Hygienist is upon you.

THE BOARD DOES NOT HAVE THE AUTHORITY TO GRANT A WAIVER OF ANY REQUIREMENT.

IF THIS APPLICATION IS INCOMPLETE UPON ONE (1) YEAR OF RECEIPT, THE APPLICATION AND SUPPORTING DOCUMENTATION WILL BECOME NULL AND VOID.

Application fee payment method: ____ Check ____ Money Order _____ Credit Card Type: ____MC _____Visa Credit Card #: ______Expiration date: ______Amount $150.00

New Mexico Regulation and Licensing Department BOARDS AND COMMISSION DIVISION Revision date: 02/2012 Page 6 of 13 New Mexico Regulation and Licensing Department BOARDS AND COMMISSION DIVISION Revision date: 02/2012 Page 7 of 13 VERIFICATION OF HOURS

Your verification should include days per week, weeks per year, and in what years so that it can actually verify that you have met those requirements. Simply having a form signed by a dentist and notarized is not enough information. If the hours need to be verified from several employers then we need the same kind of information from each until you have adequate hours recorded. The employer dentist, bookkeeper of the clinic, etc. with notarization then would sign each form.

If you can not get the information from an employer then you may write the information of hours worked and attach a copy of your W-2 forms that would confirm the information to a reasonable degree.

New Mexico Regulation and Licensing Department BOARDS AND COMMISSION DIVISION Revision date: 02/2012 Page 8 of 13 AGREEMENT FOR CONSULTING DENTISTS

I ______, DDS/DMD agree to serve as a consulting dentist to ______, RDH, for the following groups or patients wishing to receive services.

I agree to accept all patients.

I further agree to abide by all Board of Dental Health Care Rules, Part 17, pertaining to Collaborative Dental Hygiene Practice as allowed in New Mexico Statute, § 61-5A-4, D & E.

Dentist Signature: Date: Name: (printed) Practice Address: Practice Telephone Number: New Mexico DD License Number ______

I, ______, RDH agree to serve as a Collaborative Dental Hygienist with ______, DDS/DMD and agree to follow the protocol appended to this agreement. I further agree to abide by all Board of Dental Health Care Rules, Part 17, pertaining to Collaborative Dental Hygiene Practice as allowed in New Mexico Statute, § 61-5A-4, D & E.

Hygienist Signature: Date: Name: (printed) Practice Address: Practice Telephone Number: New Mexico DH License Number:

New Mexico Regulation and Licensing Department BOARDS AND COMMISSION DIVISION Revision date: 02/2012 Page 9 of 13 Clinical Protocol - DRAFT

All protocols include review of medical history, charting of existing teeth, restorations, periodontal charting and notations of any potential pathology as noted in Rules. Protocols for children 12 and under: Panoramic x-ray at age (s) ______Occlusal x-rays at age (s) ______Two or four x-rays bitewings at intervals of ______Prophylaxis/scaling at intervals of ______Topical fluoride applications at each prophylaxis/scaling appointment Periodontal charting when tissue inflammation and/or radiographic evidence indicates potential gingival/perio pathology. Protocol for teenagers: Panoramic x-ray at approximate age (s) ______Four bitewings at intervals of ______Prophylaxis/scaling at intervals of ______Topical fluoride applications at each prophylaxis/scaling appointment until age ______Periodontal charting when tissue inflammation and/or radiographic evidence indicates potential gingival/perio pathology. Protocols for adults: Full mouth or panoramic radiographs every ______years. Bitewing x-rays annually. Periodontal Charting every ______Prophylaxis/scaling every ______months. Gross debridement and scaling & root planning following consultation with consulting dentist regarding periodontal involvement.

Deviations from these agreed upon intervals will be done following collaboration between the Collaborative Practice Hygienist and Consulting Dentist with orders/prescription from dentist kept in patient's file.

Procedures preformed by the hygienist which require diagnosis will be done following consultation and order/prescription from the dentist i.e. sealants, bleaching.

______Collaborative Dental Hygienist DATE

______Consulting Dentist DATE

Additional items should be considered and may be attached.

New Mexico Regulation and Licensing Department BOARDS AND COMMISSION DIVISION Revision date: 02/2012 Page 10 of 13 Dental Hygiene Consent Form - DRAFT

FOR THE PATIENT: Please read and sign before treatment. Parent or guardian must sign for a minor (a child under the age of 18).

1. Patients are expected to keep and to be on time for appointments. a. If a patient habitually cancels (without 24 hour notice), is habitually late, or does not show for appointments, we reserve the right to refuse further treatment. b. If a patient is late and the practitioner does not have time to treat the patient, the patient will need to reschedule.

2. Children under the age of 18 must be accompanied throughout the appointment period by a parent or guardian.

a. A child may not be dropped off and left without a parent or guardian being present during treatment. b. If a parent or guardian must leave the child, arrangements must be made for the parent or legal guardian to leave a signed consent to treat form with the practitioner. c. Only the patient receiving treatment will be allowed in the treatment area. Other individuals accompanying the patient must wait in the reception area unless a practitioner specifically asks for someone to enter the treatment area. d. Children usually respond better to treatment when a parent or guardian remains in the reception area during treatment.

3. It is understood that: a. Radiographs (x-rays) must be taken as necessary for treatment. b. Patients may, upon a practitioner’s request, pick up their radiographs, following evaluation by the consulting dentist, and take them to a dentist of their choice. Patients should contact the office to request that their radiographs be prepared for pick-up. A duplication fee may be required. c. Fluoride treatment will be provided to patients when indicated in protocol unless contraindications to such treatment are indicated. d. Treatment may be refused if, in the judgment of the practitioner, it is in the best interest of the patient to do so. e. It is possible that during treatment a defective restoration may be inadvertently removed. We do not assume responsibility for replacement of the restoration. f. Radiographs will be sent to a consulting dentist or the patient’s dentist of record.

4. Payment is expected when services are rendered. a. If more than one appointment is needed to complete treatment, payment is expected at the first appointment. b. Only checks, cash, and credit cards are accepted as payment. Insurance and Medicaid will be accepted from eligible patients.

New Mexico Regulation and Licensing Department BOARDS AND COMMISSION DIVISION Revision date: 02/2012 Page 11 of 13 c. If payment is not rendered at the first appointment, we reserve the right to discontinue treatment. d. If the patient chooses not to return to complete treatment, fees are not refundable.

5. Patients are required to answer all requests for information fully and truthfully. a. Patients should advise the practitioner of any allergies and/or other health problems. b. Practitioner will not perform treatment if the patient fails to provide adequate information.

6. The assessment received by the collaborative practice dental hygienist does not constitute a comprehensive dental examination. The patient should be seen by a dentist on an annual basis. If it has been indicated that further dental treatment is needed the patient should seek care by a dentist.

I have read, understand and agree to comply with the above policies and I request dental hygiene services that are necessary for proper treatment of my oral condition.

PATIENT’S OR GUARDIAN SIGNATURE (PARENT OR GUARDIAN) DATE

______This is simply an example of what you might want to use. It may be added to or have things eliminated in order to comply with the situation between the CPDH and Consulting Dentist. PATIENT’S NAME ______Date ______

New Mexico Regulation and Licensing Department BOARDS AND COMMISSION DIVISION Revision date: 02/2012 Page 12 of 13 Our services should not be substituted for a complete dental examination, a dental examination should be performed by a dentist at least every 12 months. We encourage further services from the family dentist. Our evaluation shows:

Urgent Need 

Earliest possible appointment 

Routine follow-up care encouraged 

COMMENTS:

______

Collaborative Dental Hygienists’ Signature______

Patient or Guardian Signature______

This is simply an example of a referral form. Please alter to make it comply with the CPDH and Consulting Dentist

New Mexico Regulation and Licensing Department BOARDS AND COMMISSION DIVISION Revision date: 02/2012 Page 13 of 13