General Supervision Agreement

for Supervising Dentist and

Dental Hygienist Practicing in

Public or Private Schools

or Public or Private Institutions

Supervising Dentist: ___________________________________________________________

Work Address: _________________________________________________________________

Work Phone: ______________________________ Work Fax: ___________________________

Email Address: _____________________________ License #: __________________________

License status: _________________________ (3 years valid, good standing required)

Dental Hygienist:      ___________________________________________________________

Address where the hygienist can be contacted: _________________________________________________________________

Telephone: __________________________ Fax: _________________________

Email: _____________________________________ License #: _________________________

Years of clinical practice experience: ____________________ (3 years minimum is required)

License status: ___________________ (Valid, good standing for last 3 years required)

*Professional Liability Insurance Name: ________________________________

*Policy #: ___________________________________ *Expiration Date: __________________

*References: __________________________

* Letters of Recommendation :___________________

* = Not a legal prerequisite for this agreement

Public or private school(s) or institution(s) where hygiene services will be provided: _________________________________________________________

Address:         ____________________________________________________________________________________________________________________________________

Town or City  ___________________________________ Zip Code _______________

Phone:            ___________________________________

Fax:                ___________________________________

*Administrative Contact: _______________________________________________________________

*Email Address: _______________________________________

Responsibilities of Supervising Dentist and Dental Hygienist:

The parties agree that:

(1) The dental hygienist will practice according to the parameters set forth in this agreement.

(2) The dentist providing general supervision must be available for consultation but is not required to be physically present at the site where dental hygiene services are provided.

(3) The dental hygienist working under this agreement and supervising dentist agree to maintain communication and consultation with each other.

(4) The hygienist will provide the dentist opportunities to review patient records as requested.

(5) The dentist will review the records of patients treated by the dental hygienist from the beginning of general supervision. Reviews will include records of all patients seen. Reviews must occur no less than once every 6 (six) months at a minimum. The dentist may determine the need for and conduct more frequent reviews. Subsequent reviews of records need only encompass patients seen since the last review.

(6) Limitation on treatment:

(a)When the patient’s dental condition requires services beyond what the hygienist can provide, the hygienist will advise or refer the patient to obtain dental or other care.

(b) For patients who have been treated by a dental hygienist under general supervision and since treatment began have not been seen or examined by a dentist in 24 months, the hygienist should inform the patient or guardian that an examination by a dentist is strongly recommended.

(7) Consent form: The hygienist will, as appropriate, obtain written consent from the patient, parent or guardian on a form that may include:

“I understand that the records for services provided by the dental hygienist will be reviewed by a Vermont licensed dentist providing the hygienist general supervision.

I understand that treatment I receive from the dental hygienist is limited in scope. It does not take the place of a regular dental examination or treatment by a licensed dentist.

I understand that the dental hygienist may refer ___________ (name of patient) to a dentist or other specialist for further treatment when a dental condition requires more treatment that the dental hygienist can provide.”

                        _________________________________________ ______________

                           Signature of patient, parent or guardian Date signed

If a school or institution obtains consent for dental hygiene services provided at its facilities, the dental hygienist shall make and document reasonable efforts to ensure that the consent form used by the school or institution provides an equivalent notice and that patients, parents or guardians are aware of the information in the consent form above.

The hygienist will ensure that patient records are properly maintained and comply with applicable state or federal laws.

Authorized services. The parties agree that the dental hygienist may provide the following services: (See, List of Board authorized services in Rule 10.6 for guidance).

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________( attach separate sheets if necessary)

Limitations, or other understandings (if any) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

A copy of the agreement will be sent to:

The Board of Dental Examiners

Vermont Secretary of State

Office of Professional Regulation

National Life Bldg., North, FL2

Montpelier, VT 05620-3402.

The dentist and hygienist shall retain copies of this agreement for seven years.

Unless modified before, this agreement shall expire on ________________ (not more than one year after effective date.)

_______________________________                                                          _______________

Supervising Dentist signature                                                                                     (Date)

________________________________                                                        _______________

Dental Hygienist signature                                                                                         (Date)

The following is not part of the Rules:

Board Suggestions regarding General Supervision of Dental Hygienists practicing in public or private schools or public or private institutions as permitted by 26 V.S.A. § 854.

Because of the nature of the relationship between the dentist providing general supervision and the supervised dental hygienist practicing as permitted by statute and these rules, the Board of Dental Examiners recommends:

1) that each of the parties verify the license status of the other. This information is available from the Board’s web site, http://vtprofessionals.org and from the Office of Professional Regulation;

2) that the parties consider asking for references where they are not already familiar with each other’s practice;

3) that the parties follow good business practices which may include verifying insurance status.