These are sample documents and may be edited and/or reformatted for use by the public health dental hygienist.

Public health dental hygienists should read and understand the rules and regulations governing the practice of dentistry in Massachusetts ensuring that the documents they use follow the requirements established by the Board of Registration in Dentistry.

Collaborative Agreement

Before performing a procedure or providing a service, a public health dental hygienist shall enter into a written collaborative agreement with a local or state government agency or institution or with a licensed dentist who states that he shall be able to provide the appropriate level of communication and consultation with the dental hygienist to ensure patient health and safety, (Chapter 530 of the Acts of 2008; Section 7) (234 CMR 5.08(3)).

Consent Form

The public health dental hygienist shall obtain written informed consent of the patient or legal representative which complies with the Board regulations 234 CMR 5.15(3)(f), and, informing the patient or legal representative that the services provided by the public health dental hygienist are not a substitute for a dental examination by a dentist and informs the patient that the patient or legal representative that the patient should obtain or should have had, a dental examination by a dentist within 90 days, (234 CMR 5.08(1)(e)).

Written Information Sheet

The public health dental hygienist shall provide each patient with a written Information Sheet at the conclusion of the patient's visit, (234 CMR 5.08(1)(f)).

Health Insurance Portability and Accountability Act (HIPAA)

The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes.

Supply List

This resource will assist public health dental hygienists in considering the supplies he/she may need in a public health setting.




This information is provided by the Oral Health within the Department of Public Health.