Penn Dental License App
Content
Dentist (Rev. 08/12)
PENNSYLVANIA STATE BOARD OF DENTISTRY P.O. BOX 2649 HARRISBURG, PA 17105-2649
APPLICATION FOR A LICENSE TO PRACTICE DENTISTRY
Instructions and Application Form
Introduction:
Please read the following instructions in their entirety. These instructions will assist in the application process for an initial license to practice dentistry in Pennsylvania. The checklist format will assist you in requesting and submitting the appropriate documentation necessary to meet the licensure requirements. There are two methods by which you may apply for your Pennsylvania dental license. Licensure by Examination is for applicants who have successfully completed one of the following regional board clinical examinations: NERB, CRDTS, WREB, SRTA, or CITA. Licensure by Criteria Approval is for applicants who have obtained a license in another state based on completion of that state’s clinical examination. That state must: 1) Provide information that the State clinical examination required for licensure is comparable to the North East Regional Board Examination. 2) Provide certification of your examination scores. 3) Have requirements for licensure that meet or exceed the standards for licensure in Pennsylvania. 4) Submit certification that it will reciprocate with Pennsylvania on the basis of criteria approval.
Instructions Checklist
The following documents are required for a license to practice dentistry: A. Application Forms – Pages 1 & 2 Page 1 – Method of Application Examination (For applicants who have completed a REGIONAL CLINICAL examination) Submit a check or money order in the amount of $20.00 made payable to the “Commonwealth of PA”.
OR
Criteria Approval (For applicants who have completed a STATE CLINICAL examination, and who are currently licensed in another state that meets the criteria approval requirements) Submit a check or money order in the amount of $35.00 made payable to the “Commonwealth of PA”.
Note: Do not send cash. Application fees are non-refundable. Check or money order must be drawn on a U.S. bank. A processing fee of $20.00 will be charged for any check or money order returned unpaid by your bank, regardless of the reason for non-payment.
Dentist (Rev. 08/12)
Page 1 – Applicant Information Verification of Name: If any document required for licensure is in a name other than the name under which you applied, a photocopy of the appropriate name change document must be attached. The only documents accepted by the Board are a marriage certificate, a divorce decree that reflects the retaking of a maiden name, or court issued legal name change document. Social Security Number: A U.S. Individual Taxpayer Identification Number (ITIN) or a Canadian Social Insurance Number (SIN) cannot be accepted. A license will not be issued without a valid U.S. Social Security Number. Federal and state laws require you to disclose your Social Security Number on your application. It is mandatory in order for the Board to comply with the requirements of the federal Social Security Act pertaining to child support enforcement, as implemented in the Commonwealth of Pennsylvania at 23 Pa. C.S. § 4304.1(a). Section 301.1(a) (2) of Act 124 of 1996 amends the Domestic Relations Code. All government agencies are mandated under the Act to require the social security number of an individual on any application for a professional or occupational license. The Act also requires government agencies, including the Bureau of Professional and Occupational Affairs, to provide a licensee's name, address, and social security number to the Department of Public Welfare. The amendments were authorized under the Federal Welfare Reform Act known as the Federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Additionally, disclosing the number is mandatory in order for the Board to comply with the reporting requirements of the federal Healthcare Integrity and Protection Data Bank. All reports to the HIPDB must include the licensee's social security number. A social security number is mandated under Section 1128E of the Social Security Act. Page 1 – Current or Previous Licensure History List each state, territory, or country where you have ever held a license to practice dentistry whether the license(s) is active or inactive, current or expired. Page 2 – Practice Activity List in chronological order your practice activities since graduation from dental school. All time periods should be documented. If you did not practice dentistry during a specific time period, the timeframe should be documented as “no practice in dentistry”. Note: Practice activity should include any advanced education/training programs. Page 2 – Personal History Information If you respond “YES” to any of the personal history questions, you must submit the following: A written letter of explanation must be submitted to the Board outlining the details of the “YES” response(s). Certified copies of the record relating to the action taken. It is your responsibility to request and submit certified copies of court documents directly to the Board office. If you have been disciplined by another state licensing board, certified copies of the disciplinary record must be submitted directly to the Board office in a sealed official state board envelope. Page 2 - Certification Statement Please read the certification statement in its entirety, sign and date.
Dentist (Rev. 08/12)
B.
Certification of Graduation – Page 3 The dentistry school must complete the Certification of Graduation form, (page 3) of the application and return the completed form directly to the Board office in a sealed official school envelope. Do not submit transcripts. Note: The form cannot be completed, signed, or postmarked prior to graduation. Candidates for licensure as a dentist must have graduated from a dentistry program accredited by the Commission on Accreditation of the American Dental Association. Certification of Graduation from a foreign educational program does not meet the educational qualifications for licensure in Pennsylvania. A candidate that has received their professional education outside of the United States in a non-accredited school must conform to Section 33.102(a)(2) of the Board’s Regulations.
C.
Clinical Examination Applicants by EXAMINATION – For applicants who have successfully completed NERB, WREB, CRDTS, SRTA, or CITA – follow the instructions outlined below for Examination Results. (If you completed a State clinical examination, please follow the instructions for Criteria Approval listed below). Examination Results NERB: The Pennsylvania State Board of Dentistry has NERB examination scores from 1979 through the present on file in the Board office. Therefore, scores should be available upon receipt of your application. If you took the North East Regional Board examination prior to 1979, you must request the North East Regional Board of Dental Examiners, Inc. to forward a report of your grades directly to the Pennsylvania State Board of Dentistry. To make your request, contact the North East Regional Board Examiners, Inc., 8484 Georgia Avenue, Suite 900, Silver Spring, MD 20910. Telephone Number: (301) 563-3300. CRDTS, CITA, SRTA or WREB: You must contact the testing agency to have your detailed examination results submitted directly to the Pennsylvania State Board of Dentistry. To make your request, contact: CRDTS CITA SRTA WREB Central Regional Dental Testing Service 1725 Gage Blvd. Topeka, KS 66604 Council of Interstate Testing Agencies 1003 High House Road, Suite 101 Cary, NC 27513 Southern Regional Testing Agency 4698 Honeygrove Road, Suite 2 Virginia Beach, VA 23455 Western Regional Examining Board 23460 N 19th Avenue, Suite 210 Phoenix, AZ 85027 OR Applicants by CRITERIA APPROVAL – For applicants licensed in another state, who have completed a State clinical examination for licensure in that state: Request the Dental Board in the state where you are licensed to forward a certification directly to the Pennsylvania State Board of Dentistry in a sealed official envelope confirming that the state would consider Pennsylvania applicants for licensure in that state on the basis of criteria approval (reciprocity). The certification letter must be signed by an authorized official of the State Board contain the official seal of the state licensing board. 785-273-0380 919-460-7750 757-318-9082 602-944-3315
Dentist (Rev. 08/12)
Request the Dental Board in the state where you are licensed to forward the requirements for licensure in that state. Request an official certification of your examination scores for the clinical examination you completed for licensure in that state. The scores must include the specific components of the examination, the score obtained in each section of the examination and the maximum points possible in each section of the examination. D. National Board Scores The applicant must request the Joint Commission on National Dental Examinations to forward a report of your written grades directly to the Pennsylvania State Board of Dentistry. A photocopy or candidate copy is not acceptable. Scores are retained in the Board office for one (1) year from the date the scores are received. If you previously requested scores be sent to the Pennsylvania State Board of Dentistry more than one (1) year ago, you must request a new report of your written grades to be forwarded directly to the Board office. To make your request, contact the Joint Commission on National Dental Examinations, 211 East Chicago Avenue, Suite 1846, Chicago, IL 60611. Telephone Number: (312) 440-2678. E. Verification of Licensure Request a letter of good standing from each state or territory where you hold or have ever held a license to practice dentistry, whether active, inactive, current or expired. The letter(s) of good standing must contain the proper signature, date and seal of the licensing authority and must be sent directly to the Pennsylvania State Board of Dentistry in a sealed official envelope of the state licensing board. Note: If you have been disciplined by a state licensing board, the letter of good standing must include certified copies of the disciplinary record. F. Letter of Recommendation If you do not hold a license to practice dentistry in another state, and you are enrolled in a residency program, or in the military service, you must request the Residency Program Director or Commanding Officer in the military service submit a letter of recommendation. The official letter must be submitted directly to the Board office in a sealed official envelope. G. National Practitioner Data Bank / Healthcare Integrity and Protection Data Bank If you hold or have held a license to practice dentistry (active or inactive, current or expired) in another state(s), you must request a self-query. You would need to obtain the Self-Query at www.npdbhipdb.hrsa.gov. Once the report is completed and available, you must print the report from the above-listed website and submit directly to the Board office. H. CPR Certification Attach a photocopy of your current CPR certification card (front and back). The card must show current certification in Infant, Child and Adult CPR through an approved provider in accordance with the Board’s Regulations. Note: Online CPR certification courses are not accepted. The photocopy must be submitted on an 8 ½ x 11 sheet of paper.
Dentist (Rev. 08/12)
I.
Board Office Mail your fee, pages 1 and 2 of your application, CPR certification, data bank self-query response, and if necessary, a copy of your name change document, directly to the Board office: Mailing Address State Board of Dentistry P.O. Box 2649 Harrisburg, PA 17105-2649 Street Address (Courier Delivery) State Board of Dentistry One Penn Center 2601 North Third Street Harrisburg, PA 17110
All other documentation must be submitted directly from the certifying state board, educational institution and/or organization.
IMPORTANT INFORMATION
You may not practice dentistry in the Commonwealth of Pennsylvania until the Pennsylvania State Board of Dentistry has issued a license. Under the Dental Law, in order to practice dentistry in the Commonwealth of Pennsylvania, you are required to have medical professional liability insurance in the minimum of one million dollars ($1,000,000) per occurrence or claim and three million dollars ($3,000,000) per annual aggregate. Acceptable coverage shall include: 1) 2) 3) 4) Personally purchased medical professional liability insurance; Self-insurance; Medical professional liability insurance coverage provided by the d entist’s employer; or Medical professional liability insurance coverage provided by the community-based clinic for dentists with a volunteer license.
Therefore, you have 60 days from the date your license is issued to provide proof of acceptable coverage which may include a certificate of insurance issued by the insurer or a copy of the declarations page of the professional liability insurance policy. For professional liability insurance coverage through the dentist’s employer, documentation must reflect you as a named insured. Failure to do so may result in your professional license being refused, revoked or suspended by the Board. It is your responsibility to maintain a copy of this application for future reference. The Board’s application forms must be submitted in their original format and may not be altered. Altered forms will be rejected and cause further delay in the processing of your application. The Board office does not verify receipt of mail. Processing time varies depending upon the workload. Average processing time upon receipt of all required documentation is approximately 10-15 business days. However, during busy periods (i.e. renewal, graduation, etc.) and for applications that require Board review, processing times may
exceed the 10-15 business days.
Once your application has been processed, you may check on the status of your application and/or issuance of your license through the Board’s website at www.mylicense.state.pa.us. Should the application not be completed within six months, updated documentation may be required. Additionally, if the application process has not been completed within one year from the date it was received, applicants will be required to submit an updated application-processing fee. All licenses, regardless of the date of issuance, expire on March 31 st of the odd-numbered years. The Dental Law and Regulations requires that you maintain current infant, child and adult CPR certification. The Board’s Regulations require dentists to complete 30 credit hours each biennial period. regulations pertaining to continuing education are available at www.dos.state.pa.us/dent. The specific
You are required to notify the Board within 10 days of an address change. Changes of address may be submitted in writing by mail, fax, or online at www.mylicense.state.pa.us. Acknowledgement and information on using the Board’s online services will be sent to you on receipt and input of your application. A change of address will not be accepted by email.
Dentist (Rev. 08/12)
PENNSYLVANIA STATE BOARD OF DENTISTRY P.O. BOX 2649 HARRISBURG, PA 17105-2649
Telephone: 717-783-7162 Facsimile: 717-787-7769 Website: www.dos.state.pa.us/dent Email: [email protected]
APPLICATION FOR A LICENSE TO PRACTICE DENTISTRY
METHOD OF APPLICATION
Please check one of the following: Examination ($20.00) Criteria Approval ($35.00)
APPLICANT INFORMATION
NAME: _________________________________________________________________________________________________
LAST FIRST MIDDLE
ADDRESS: ______________________________________________________________________________________________
STREET
____________________________________________________________________________________________
CITY STATE ZIP CODE
U.S. Social Security Number: Date of Birth: – –
–
– Telephone Number: Yes NERB CRDTS
*ETIN or SIN cannot be accepted. ( ) or CITA No SRTA WREB –
Did you take the National Board examination? Regional examination completed (circle one):
or
State Clinical Examination completed: Please specify the date(s):
_______________________________________________________ Month_________________________Year____________________
If any document required for licensure is in a name other than above, please indicate the name(s). A copy of the appropriate name change document must be attached. ________________________________________________________
CURRENT OR PREVIOUS LICENSURE HISTORY
Yes Have you ever possessed a license to practice dentistry (active or inactive, current or expired) in another state, territory or country? If “yes”, please list below. You will need to request a letter of good standing from each state licensing board. State or Jurisdiction Active or Inactive License Obtained by: Examination Other No
1
Dentist (Rev. 08/12)
PRACTICE ACTIVITY
Yes Have you engaged in the practice of dentistry since gradation from dental school? (This includes advanced education/post-graduate training) If yes, please list in chronological order your practice activities since graduation from dental school. All time periods should be documented. If you did not practice during a specific time period, the timeframe should be documented as “no practice in dentistry”. If additional space is needed, please attach on a separate 8½ x 11 sheet of paper. Dates Employment Information (Name, City, State) From To Description of practice activity
(Month/Yr) (Month/Yr)
No
PERSONAL HISTORY INFORMATION
Please check Yes or No to each of the following questions: 1) Has any action involving your licensed profession, disciplinary or otherwise, been taken against you or your license (including a voluntary surrender of a license) in any state or jurisdiction or charges filed against you that have not been resolved? Have you withdrawn an application for a license, had an application for a license denied or refused or agreed not to apply for a license in another state, territory or country? Have you been convicted, found guilty or pleaded guilty or entered a plea of nolo contendere, or received probation without verdict, accelerated rehabilitative disposition (ARD) or received any other disposition (excluding acquittal or dismissal) of any criminal charges, felony or misdemeanor, including any DUI/DWI, drug law violations, or are there any criminal charges pending and unresolved in any State or Federal Court? Have you had practice privileges (denied, revoked, suspended or restricted in lieu of discipline in a hospital or any health care facility? Have you had your DEA registration denied, revoked or restricted or have you had your provider privileges terminated by any medical assistance agency for cause? Have you experienced difficulties as a result of alcohol or other drugs such as diagnosis of/treatment for dependency or abuse or arrests for chemical-use-related offenses? YES NO
2) 3)
4) 5) 6)
CERTIFICATION STATEMENT
I hereby certify that I have read the Pennsylvania Dental Law, Act 216 and Regulations, Pennsylvania Code, Title 49. Professional and Vocational Standards and I will abide by the Board’s Laws and Regulations while practicing in the Commonwealth of Pennsylvania. By signing below, I verify that this form is in the original format as supplied by the Department of State and has not been altered or otherwise modified in any way. I am aware of the criminal penalties for tampering with public records or information pursuant to 18 Pa. C.S.§4911. Additionally, I certify that the statements in this application are true and correct to the best of my knowledge, information and belief, and that I am of good moral character. I understand that any false statement made is subject to the penalties of 18 Pa. C.S.§4904 relating to unsworn falsification to authorities and may result in the suspension or revocation of my license, permit or certificate. Signature of Applicant: _______________________________________________________ Date: _____________________
2
Dentist (Rev. 08/12)
STATE BOARD OF DENTISTRY P.O. BOX 2649 HARRISBURG, PA 17105-2649
APPLICATION FOR A LICENSE TO PRACTICE DENTISTRY IN PENNSYLVANIA
CERTIFICATION OF GRADUATION
Section A – To be completed by the applicant:
NAME:
______________________________________________________________________________________ ___________
LAST FIRST MIDDLE
ADDRESS: ______________________________________________________________________________________________
STREET
____________________________________________________________________________________________
CITY STATE ZIP CODE
Section B – To be completed by the proper official of the school:
**Applicants may not complete this section of the certification form**
I certify that _____________________________________________________________ successfully completed the required
Name of Applicant
courses in the study of dentistry and was graduated from the following program: Name of Dentistry School: ___________________________________________________________________________ City and State: __________________________________________ Date of Graduation: ________________________________ I further certify that this dentistry education program is accredited by the Commission on Accreditation of the American Dental Association.
______________________________________________________________
Signature of Proper Official of School
______________________________________________________________
Date ( SEAL OF SCHOOL )
*FORM MUST BE RETURNED DIRECTLY TO THE BOARD OFFICE IN A SEALED OFFICIAL SCHOOL ENVELOPE
(Note: Form may not be completed, signed, or submitted prior to graduation)
3
PENNSYLVANIA STATE BOARD OF DENTISTRY P.O. BOX 2649 HARRISBURG, PA 17105-2649
APPLICATION FOR A LICENSE TO PRACTICE DENTISTRY
Instructions and Application Form
Introduction:
Please read the following instructions in their entirety. These instructions will assist in the application process for an initial license to practice dentistry in Pennsylvania. The checklist format will assist you in requesting and submitting the appropriate documentation necessary to meet the licensure requirements. There are two methods by which you may apply for your Pennsylvania dental license. Licensure by Examination is for applicants who have successfully completed one of the following regional board clinical examinations: NERB, CRDTS, WREB, SRTA, or CITA. Licensure by Criteria Approval is for applicants who have obtained a license in another state based on completion of that state’s clinical examination. That state must: 1) Provide information that the State clinical examination required for licensure is comparable to the North East Regional Board Examination. 2) Provide certification of your examination scores. 3) Have requirements for licensure that meet or exceed the standards for licensure in Pennsylvania. 4) Submit certification that it will reciprocate with Pennsylvania on the basis of criteria approval.
Instructions Checklist
The following documents are required for a license to practice dentistry: A. Application Forms – Pages 1 & 2 Page 1 – Method of Application Examination (For applicants who have completed a REGIONAL CLINICAL examination) Submit a check or money order in the amount of $20.00 made payable to the “Commonwealth of PA”.
OR
Criteria Approval (For applicants who have completed a STATE CLINICAL examination, and who are currently licensed in another state that meets the criteria approval requirements) Submit a check or money order in the amount of $35.00 made payable to the “Commonwealth of PA”.
Note: Do not send cash. Application fees are non-refundable. Check or money order must be drawn on a U.S. bank. A processing fee of $20.00 will be charged for any check or money order returned unpaid by your bank, regardless of the reason for non-payment.
Dentist (Rev. 08/12)
Page 1 – Applicant Information Verification of Name: If any document required for licensure is in a name other than the name under which you applied, a photocopy of the appropriate name change document must be attached. The only documents accepted by the Board are a marriage certificate, a divorce decree that reflects the retaking of a maiden name, or court issued legal name change document. Social Security Number: A U.S. Individual Taxpayer Identification Number (ITIN) or a Canadian Social Insurance Number (SIN) cannot be accepted. A license will not be issued without a valid U.S. Social Security Number. Federal and state laws require you to disclose your Social Security Number on your application. It is mandatory in order for the Board to comply with the requirements of the federal Social Security Act pertaining to child support enforcement, as implemented in the Commonwealth of Pennsylvania at 23 Pa. C.S. § 4304.1(a). Section 301.1(a) (2) of Act 124 of 1996 amends the Domestic Relations Code. All government agencies are mandated under the Act to require the social security number of an individual on any application for a professional or occupational license. The Act also requires government agencies, including the Bureau of Professional and Occupational Affairs, to provide a licensee's name, address, and social security number to the Department of Public Welfare. The amendments were authorized under the Federal Welfare Reform Act known as the Federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Additionally, disclosing the number is mandatory in order for the Board to comply with the reporting requirements of the federal Healthcare Integrity and Protection Data Bank. All reports to the HIPDB must include the licensee's social security number. A social security number is mandated under Section 1128E of the Social Security Act. Page 1 – Current or Previous Licensure History List each state, territory, or country where you have ever held a license to practice dentistry whether the license(s) is active or inactive, current or expired. Page 2 – Practice Activity List in chronological order your practice activities since graduation from dental school. All time periods should be documented. If you did not practice dentistry during a specific time period, the timeframe should be documented as “no practice in dentistry”. Note: Practice activity should include any advanced education/training programs. Page 2 – Personal History Information If you respond “YES” to any of the personal history questions, you must submit the following: A written letter of explanation must be submitted to the Board outlining the details of the “YES” response(s). Certified copies of the record relating to the action taken. It is your responsibility to request and submit certified copies of court documents directly to the Board office. If you have been disciplined by another state licensing board, certified copies of the disciplinary record must be submitted directly to the Board office in a sealed official state board envelope. Page 2 - Certification Statement Please read the certification statement in its entirety, sign and date.
Dentist (Rev. 08/12)
B.
Certification of Graduation – Page 3 The dentistry school must complete the Certification of Graduation form, (page 3) of the application and return the completed form directly to the Board office in a sealed official school envelope. Do not submit transcripts. Note: The form cannot be completed, signed, or postmarked prior to graduation. Candidates for licensure as a dentist must have graduated from a dentistry program accredited by the Commission on Accreditation of the American Dental Association. Certification of Graduation from a foreign educational program does not meet the educational qualifications for licensure in Pennsylvania. A candidate that has received their professional education outside of the United States in a non-accredited school must conform to Section 33.102(a)(2) of the Board’s Regulations.
C.
Clinical Examination Applicants by EXAMINATION – For applicants who have successfully completed NERB, WREB, CRDTS, SRTA, or CITA – follow the instructions outlined below for Examination Results. (If you completed a State clinical examination, please follow the instructions for Criteria Approval listed below). Examination Results NERB: The Pennsylvania State Board of Dentistry has NERB examination scores from 1979 through the present on file in the Board office. Therefore, scores should be available upon receipt of your application. If you took the North East Regional Board examination prior to 1979, you must request the North East Regional Board of Dental Examiners, Inc. to forward a report of your grades directly to the Pennsylvania State Board of Dentistry. To make your request, contact the North East Regional Board Examiners, Inc., 8484 Georgia Avenue, Suite 900, Silver Spring, MD 20910. Telephone Number: (301) 563-3300. CRDTS, CITA, SRTA or WREB: You must contact the testing agency to have your detailed examination results submitted directly to the Pennsylvania State Board of Dentistry. To make your request, contact: CRDTS CITA SRTA WREB Central Regional Dental Testing Service 1725 Gage Blvd. Topeka, KS 66604 Council of Interstate Testing Agencies 1003 High House Road, Suite 101 Cary, NC 27513 Southern Regional Testing Agency 4698 Honeygrove Road, Suite 2 Virginia Beach, VA 23455 Western Regional Examining Board 23460 N 19th Avenue, Suite 210 Phoenix, AZ 85027 OR Applicants by CRITERIA APPROVAL – For applicants licensed in another state, who have completed a State clinical examination for licensure in that state: Request the Dental Board in the state where you are licensed to forward a certification directly to the Pennsylvania State Board of Dentistry in a sealed official envelope confirming that the state would consider Pennsylvania applicants for licensure in that state on the basis of criteria approval (reciprocity). The certification letter must be signed by an authorized official of the State Board contain the official seal of the state licensing board. 785-273-0380 919-460-7750 757-318-9082 602-944-3315
Dentist (Rev. 08/12)
Request the Dental Board in the state where you are licensed to forward the requirements for licensure in that state. Request an official certification of your examination scores for the clinical examination you completed for licensure in that state. The scores must include the specific components of the examination, the score obtained in each section of the examination and the maximum points possible in each section of the examination. D. National Board Scores The applicant must request the Joint Commission on National Dental Examinations to forward a report of your written grades directly to the Pennsylvania State Board of Dentistry. A photocopy or candidate copy is not acceptable. Scores are retained in the Board office for one (1) year from the date the scores are received. If you previously requested scores be sent to the Pennsylvania State Board of Dentistry more than one (1) year ago, you must request a new report of your written grades to be forwarded directly to the Board office. To make your request, contact the Joint Commission on National Dental Examinations, 211 East Chicago Avenue, Suite 1846, Chicago, IL 60611. Telephone Number: (312) 440-2678. E. Verification of Licensure Request a letter of good standing from each state or territory where you hold or have ever held a license to practice dentistry, whether active, inactive, current or expired. The letter(s) of good standing must contain the proper signature, date and seal of the licensing authority and must be sent directly to the Pennsylvania State Board of Dentistry in a sealed official envelope of the state licensing board. Note: If you have been disciplined by a state licensing board, the letter of good standing must include certified copies of the disciplinary record. F. Letter of Recommendation If you do not hold a license to practice dentistry in another state, and you are enrolled in a residency program, or in the military service, you must request the Residency Program Director or Commanding Officer in the military service submit a letter of recommendation. The official letter must be submitted directly to the Board office in a sealed official envelope. G. National Practitioner Data Bank / Healthcare Integrity and Protection Data Bank If you hold or have held a license to practice dentistry (active or inactive, current or expired) in another state(s), you must request a self-query. You would need to obtain the Self-Query at www.npdbhipdb.hrsa.gov. Once the report is completed and available, you must print the report from the above-listed website and submit directly to the Board office. H. CPR Certification Attach a photocopy of your current CPR certification card (front and back). The card must show current certification in Infant, Child and Adult CPR through an approved provider in accordance with the Board’s Regulations. Note: Online CPR certification courses are not accepted. The photocopy must be submitted on an 8 ½ x 11 sheet of paper.
Dentist (Rev. 08/12)
I.
Board Office Mail your fee, pages 1 and 2 of your application, CPR certification, data bank self-query response, and if necessary, a copy of your name change document, directly to the Board office: Mailing Address State Board of Dentistry P.O. Box 2649 Harrisburg, PA 17105-2649 Street Address (Courier Delivery) State Board of Dentistry One Penn Center 2601 North Third Street Harrisburg, PA 17110
All other documentation must be submitted directly from the certifying state board, educational institution and/or organization.
IMPORTANT INFORMATION
You may not practice dentistry in the Commonwealth of Pennsylvania until the Pennsylvania State Board of Dentistry has issued a license. Under the Dental Law, in order to practice dentistry in the Commonwealth of Pennsylvania, you are required to have medical professional liability insurance in the minimum of one million dollars ($1,000,000) per occurrence or claim and three million dollars ($3,000,000) per annual aggregate. Acceptable coverage shall include: 1) 2) 3) 4) Personally purchased medical professional liability insurance; Self-insurance; Medical professional liability insurance coverage provided by the d entist’s employer; or Medical professional liability insurance coverage provided by the community-based clinic for dentists with a volunteer license.
Therefore, you have 60 days from the date your license is issued to provide proof of acceptable coverage which may include a certificate of insurance issued by the insurer or a copy of the declarations page of the professional liability insurance policy. For professional liability insurance coverage through the dentist’s employer, documentation must reflect you as a named insured. Failure to do so may result in your professional license being refused, revoked or suspended by the Board. It is your responsibility to maintain a copy of this application for future reference. The Board’s application forms must be submitted in their original format and may not be altered. Altered forms will be rejected and cause further delay in the processing of your application. The Board office does not verify receipt of mail. Processing time varies depending upon the workload. Average processing time upon receipt of all required documentation is approximately 10-15 business days. However, during busy periods (i.e. renewal, graduation, etc.) and for applications that require Board review, processing times may
exceed the 10-15 business days.
Once your application has been processed, you may check on the status of your application and/or issuance of your license through the Board’s website at www.mylicense.state.pa.us. Should the application not be completed within six months, updated documentation may be required. Additionally, if the application process has not been completed within one year from the date it was received, applicants will be required to submit an updated application-processing fee. All licenses, regardless of the date of issuance, expire on March 31 st of the odd-numbered years. The Dental Law and Regulations requires that you maintain current infant, child and adult CPR certification. The Board’s Regulations require dentists to complete 30 credit hours each biennial period. regulations pertaining to continuing education are available at www.dos.state.pa.us/dent. The specific
You are required to notify the Board within 10 days of an address change. Changes of address may be submitted in writing by mail, fax, or online at www.mylicense.state.pa.us. Acknowledgement and information on using the Board’s online services will be sent to you on receipt and input of your application. A change of address will not be accepted by email.
Dentist (Rev. 08/12)
PENNSYLVANIA STATE BOARD OF DENTISTRY P.O. BOX 2649 HARRISBURG, PA 17105-2649
Telephone: 717-783-7162 Facsimile: 717-787-7769 Website: www.dos.state.pa.us/dent Email: [email protected]
APPLICATION FOR A LICENSE TO PRACTICE DENTISTRY
METHOD OF APPLICATION
Please check one of the following: Examination ($20.00) Criteria Approval ($35.00)
APPLICANT INFORMATION
NAME: _________________________________________________________________________________________________
LAST FIRST MIDDLE
ADDRESS: ______________________________________________________________________________________________
STREET
____________________________________________________________________________________________
CITY STATE ZIP CODE
U.S. Social Security Number: Date of Birth: – –
–
– Telephone Number: Yes NERB CRDTS
*ETIN or SIN cannot be accepted. ( ) or CITA No SRTA WREB –
Did you take the National Board examination? Regional examination completed (circle one):
or
State Clinical Examination completed: Please specify the date(s):
_______________________________________________________ Month_________________________Year____________________
If any document required for licensure is in a name other than above, please indicate the name(s). A copy of the appropriate name change document must be attached. ________________________________________________________
CURRENT OR PREVIOUS LICENSURE HISTORY
Yes Have you ever possessed a license to practice dentistry (active or inactive, current or expired) in another state, territory or country? If “yes”, please list below. You will need to request a letter of good standing from each state licensing board. State or Jurisdiction Active or Inactive License Obtained by: Examination Other No
1
Dentist (Rev. 08/12)
PRACTICE ACTIVITY
Yes Have you engaged in the practice of dentistry since gradation from dental school? (This includes advanced education/post-graduate training) If yes, please list in chronological order your practice activities since graduation from dental school. All time periods should be documented. If you did not practice during a specific time period, the timeframe should be documented as “no practice in dentistry”. If additional space is needed, please attach on a separate 8½ x 11 sheet of paper. Dates Employment Information (Name, City, State) From To Description of practice activity
(Month/Yr) (Month/Yr)
No
PERSONAL HISTORY INFORMATION
Please check Yes or No to each of the following questions: 1) Has any action involving your licensed profession, disciplinary or otherwise, been taken against you or your license (including a voluntary surrender of a license) in any state or jurisdiction or charges filed against you that have not been resolved? Have you withdrawn an application for a license, had an application for a license denied or refused or agreed not to apply for a license in another state, territory or country? Have you been convicted, found guilty or pleaded guilty or entered a plea of nolo contendere, or received probation without verdict, accelerated rehabilitative disposition (ARD) or received any other disposition (excluding acquittal or dismissal) of any criminal charges, felony or misdemeanor, including any DUI/DWI, drug law violations, or are there any criminal charges pending and unresolved in any State or Federal Court? Have you had practice privileges (denied, revoked, suspended or restricted in lieu of discipline in a hospital or any health care facility? Have you had your DEA registration denied, revoked or restricted or have you had your provider privileges terminated by any medical assistance agency for cause? Have you experienced difficulties as a result of alcohol or other drugs such as diagnosis of/treatment for dependency or abuse or arrests for chemical-use-related offenses? YES NO
2) 3)
4) 5) 6)
CERTIFICATION STATEMENT
I hereby certify that I have read the Pennsylvania Dental Law, Act 216 and Regulations, Pennsylvania Code, Title 49. Professional and Vocational Standards and I will abide by the Board’s Laws and Regulations while practicing in the Commonwealth of Pennsylvania. By signing below, I verify that this form is in the original format as supplied by the Department of State and has not been altered or otherwise modified in any way. I am aware of the criminal penalties for tampering with public records or information pursuant to 18 Pa. C.S.§4911. Additionally, I certify that the statements in this application are true and correct to the best of my knowledge, information and belief, and that I am of good moral character. I understand that any false statement made is subject to the penalties of 18 Pa. C.S.§4904 relating to unsworn falsification to authorities and may result in the suspension or revocation of my license, permit or certificate. Signature of Applicant: _______________________________________________________ Date: _____________________
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Dentist (Rev. 08/12)
STATE BOARD OF DENTISTRY P.O. BOX 2649 HARRISBURG, PA 17105-2649
APPLICATION FOR A LICENSE TO PRACTICE DENTISTRY IN PENNSYLVANIA
CERTIFICATION OF GRADUATION
Section A – To be completed by the applicant:
NAME:
______________________________________________________________________________________ ___________
LAST FIRST MIDDLE
ADDRESS: ______________________________________________________________________________________________
STREET
____________________________________________________________________________________________
CITY STATE ZIP CODE
Section B – To be completed by the proper official of the school:
**Applicants may not complete this section of the certification form**
I certify that _____________________________________________________________ successfully completed the required
Name of Applicant
courses in the study of dentistry and was graduated from the following program: Name of Dentistry School: ___________________________________________________________________________ City and State: __________________________________________ Date of Graduation: ________________________________ I further certify that this dentistry education program is accredited by the Commission on Accreditation of the American Dental Association.
______________________________________________________________
Signature of Proper Official of School
______________________________________________________________
Date ( SEAL OF SCHOOL )
*FORM MUST BE RETURNED DIRECTLY TO THE BOARD OFFICE IN A SEALED OFFICIAL SCHOOL ENVELOPE
(Note: Form may not be completed, signed, or submitted prior to graduation)
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