Apply for a mobile dental permit as a dental hygienist

Exemptions

Circumstances when you don't need an MDF or PDO permit:

• The service provided is for emergency treatment
• A patient of record is homebound
• The only service provided is a 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

• A written statement detailing the scope of services you will provide. Include CDT codes for each service to be provided.
• A copy of the floor plan and/or specifications of the MDF
• Photographs of all equipment, supplies, and instruments to be utilized, including all sterilizers
• A copy of current BLS certificates for all hygienists providing dental hygiene services
• A copy of your written protocol for the management of medical emergencies. Include contact information for emergency care after business hours.
• A copy of your schedule and content of regular and routine emergency drills
• A request for on-site inspection by the Board
• A copy of your schedule, protocols, and procedures for and results of weekly spore testing
• A copy of ownership documents (corporation papers, DBA, partnership agreement, business certificate) for your practice
• Copy of your logbook or protocol showing compliance with:
  • Handicap access
  • Infection control for equipment and sterilization systems
  • Access to potable 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
  • Patient protective eyewear
  • Protocol for maintenance of any other equipment necessary for services you provide
• Copies of all documents that show compliance with requirements for dental hygiene practice. This is pursuant to 234 CMR 2.03 (Public Health Dental Hygienist), 234 CMR 5.07 (2)(a) and 234 CMR 5.08.
• A copy of your collaborative agreement(s) pursuant to 234 CMR 5.07 and 5.08
• A statement indicating the location where you maintain dental records. Include your protocol on how a patient may request a copy of such records.
• Copies of informed consent form and discharge/referral information sheet