Apply for a Dentist's Mobile Dental Facility (MDF) or Portable Dental Operation (PDO) permit

Exemptions

Cases where you don't need an MDF or PDO permit:

• The service is an emergency treatment
• A patient of record is homebound
• The services are only dental screening
• The services are provided:
  • By a hospital or clinic licensed pursuant to M.G.L.c.111, §51-56
  • In a school setting approved by the Commission on Dental Accreditation of the American Dental Association
  • By a local or state government agency pursuant to M.G.L.c.112, §51

Required application attachments

The following apply if you are applying for a MDF or PDO permit:

• A written statement detailing the scope of services you will provide. Also include the current CDT code for each service.
• A copy of a schedule and log demonstrating your regular inspection of all emergency drugs and equipment for administering anesthesia & sedation. Include the date(s) and name of the person who last checked drugs and equipment, and the results of the checks. Include a statement that the condition of equipment meets manufacturers’ specifications.
• A copy of your written protocol for the management of medical emergencies. Include contact information for emergency care after business hours. 
• A copy of the schedule and content of regular and routine emergency drills
• A request for on-site inspection by the Board
• A copy of the schedule, protocols, and procedures for and results of weekly spore testing
• A copy of DPH Radiation Control Program Certification for the MDF, (M.G. L. c. 111 §5N), if applicable
• A copy of ownership documents (corporation papers, DBA, partnership agreement, business certificate) for your practice
• Copy of a logbook or protocol showing compliance with:
  • Handicap access
  • Infection control for equipment and sterilization systems (for MDFs)
  • Access to portable water
  • Access to hand washing and toilet facilities
  • Storage of local anesthesia and emergency drugs (if applicable)
  • Container for deposit of refuse and waste material as required by 310 CMR 73.00
  • Personal protection equipment (for PDOs)
  • Patient protective eyewear (for PDOs)
  • Protocol for maintenance of any other equipment necessary for services you provide
• A statement indicating the location where you maintain your dental treatment records. Include your protocol describing how a patient may request a copy of their records.
• Copies of informed consent form and discharge/referral information sheet

For MDFs/PDOs that don't administer anesthesia or local anesthesia:

• Copies of current BLS certificates for all those providing dental services, dental hygiene services, or assisting in the services you provide

For MDFs/PDOs that administer nitrous-oxide/oxygen, minimal sedation, moderate sedation, or general anesthesia:

• Copies of current ACLS/PALS or BLS certificates for all those providing dental services, dental hygiene services, or assisting in the services you provide
• For MDFs:
  • A copy of current Anesthesia Facility Permit and individual anesthesia permit(s), as applicable
• For PDOs:
  • A copy of current Facility Permit D-P or other current anesthesia permits, as applicable

Application attachments for the MDF Permit

• Fill out the Required Equipment and Emergency Drugs form on the application
• A copy of the layout/floor specifications of the MDF

Application attachments for the PDO Permit

• A statement about emergency drugs (and equipment, if applicable) to be immediately available to the PDO. See the instructions on the application.
• Photographs of all equipment, supplies, and instruments you will use in the PDO, including sterilizer