Free 50923.FH11 - Indiana

APPLICATION FOR REGISTRATION OF A MOBILE DENTAL FACILITY
State Form 50923 (R / 2-06) Approved by State Board of Accounts, 2006

INDIANA STATE BOARD OF DENTISTRY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2057 E-mail: [email protected]

* Disclosure of your Social Security number is MANDATORY according to Indiana Code 4-1-8-1. FOR OFFICE USE ONLY
Fee paid Date (month, day, year) Receipt number

FOR INDIANA BOARD OF DENTISTRY USE ONLY
Date of review (month, day, year) Decision Registration number Initials

DO NOT WRITE ABOVE THIS LINE
GENERAL INFORMATION
Legal name of business Type of application

New

Renewal

Official business or mailing address, where all dental and official records shall be maintained (number and street, city, state, and ZIP code - may not be a P.O. Box)

Website address Name of contact person

E-mail address Title

( (

Telephone number of record

) )

Fax number

Address of contact person (number and street, city, state, and ZIP code) Name of person responsible for the operation of the facility Address of person responsible for the operation of the facility (number and street, city, state, and ZIP code) List all trade or business names used by the corporation or licensee Telephone number

(

)

I do solemnly swear or affirm, under the penalties of perjury, that I am the person authorized to sign this application for registration and that the statements made are true and correct in all respects.
Signature of owner or corporate officer Printed name and title of owner or corporate officer Name of person to contact with questions concerning application Telephone number Date signed (month, day, year) Social Security number * E-mail address

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)

PHYSICAL REQUIREMENTS FOR MOBILE DENTAL FACILITY 828 IAC 4-3-4 Physical requirements for mobile dental facility Authority: IC 25-14-1-3 Authority: IC 25-14 Sec. 4. The operator shall ensure that the mobile dental facility or portable dental operation has: (1) Ready access to a ramp or lift if services are provided to disabled persons. (2) A properly functioning sterilization system. (3) Ready access to an adequate supply of potable water, including hot water. (4) Ready access to toilet facilities. (5) A covered galvanized, stainless steel, or other non-corrosive container for deposit of refuse and waste materials. The mobile dental facility referred to in this application satisfies the above physical requirements.
(Continued on reverse side)

Yes

No

NOTICE In compliance with IC 4-1-6, this agency is notifying you that you must provide the requested information or your application will not be processed. You have the right to challenge, correct, or explain information maintained by this agency. The information you provide will become public record. INDIANA LICENSED PERSONNEL Address (number and street, city, state, and ZIP code)

Full Name

Title

Telephone Number

License Number

( ( ( ( ( ( ( ( ( (
ADDITIONAL REQUIRED DOCUMENTATION

) ) ) ) ) ) ) ) ) )

1. Proof of radiographic equipment inspection from the Indiana State Department of Health. 2. Copy of written procedure for emergency follow-up care, which indicates the arrangements for follow-up care for patients treated in the mobile dental facility and that such procedure includes arrangements for treatment in a dental facility that is permanently established in the area where services were provided. (Any change in written procedure must be submitted to the board within 30 days of change.) 3. Letters of support, indicating the aforementioned arrangements for emergency follow-up care in all the areas where services are to be provided. 4. Copy of valid Indianas drivers license appropriate for the operation of the mobile dental facility. 5. Copy of consent form. 6. Copy of patient information sheet. 7. Proof of communication facilities.