Renewal Form

445 East 4500 South #130 – Salt Lake City, UT 84107 info@pieutah.org

Local Phone: 801-262-0200 Toll Free In Utah: 800-432-5743

RENEWAL FORM

Please complete, sign and submit. Then call (801-262-0200 ) to make a credit card payment.
OR
SCAN AND E-MAIL TO PIE STAFF AND THEN CALL TO MAKE CREDIT CARD PAYMENT

Please note any changes in Mailing Address, Telephone including Cell, e-mail address

In order to submit the form you are required to answer every question below. If the questions are not applicable to your practice enter NA.

Dentist Name

Policy Number

Class

Practice Name

Office Telephone

Personal Cell Phone

Address

E-mail Address

General Practice

or Specialty
Do you use Sargenti Technique/N2 Paste?

Yes Yes

No No

If so, you must use PIE Informed. Cons.
Do your hygienists give local anesthetics?

YesYes

No No

If so, do they have their own coverage?

YesYes

No No
NA NA

If not, you must carry PIE’s H-Rider.
Check if you do any of the following procedures:

Yes Nitrous Oxide Analgesia
  (Requires Class B permit with Dental License)

Yes In-office IV sedation provided by other professional
  (Requires. PIE Class II Coverage)

Yes IV or General Anesthesia provided by other professional in hospital/other setting
  (Req. PIE Class II Coverage)

Those checking either category below must fill out questions on PAGE 2.

Yes *In-office IV/IM sedation provided by you personally
  (Req.Class D Anesth. Permit)

Yes *Oral/enteral conscious sedation w/N₂O, 1 drug
  (PIE Class II coverage + Class C Anesth. Permit)

Yes *Oral/enteral conscious sedation w/N₂O, >1 drug
  (PIE Class II coverage + Class D Anesth. Permit)
Are you currently CPR Certified?

Yes Yes

No No

Up to date on required CE Hours?

Yes Yes

No No
Are you routinely using detailed Informed Consent forms designed for specific procedures?

Yes Yes

No No

If not, why not?
Note any claims filed or any threats of claims against you during the last year that have not been reported to PIE previously
List any serious or life-threatening incidents in your practice during the past year
List any change in practice status; ie you have entered into any partnership/corporate situation or associateship
List any suggestions as to how we at PIE may better serve you
AFTER LICENSE RENEWAL IN 2020, PLEASE ATTACH A COPY OF YOUR UPDATED DENTAL LICENSE USING THE SUBMIT FORM BUTTON AT THE BOTTOM OF THIS FORM.

Your policy will be automatically terminated if payment and this renewal form are not received within thirty days of the due date. For delinquent accounts after this time a $100.00 re-instatement fee may be assessed.

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT ANY FALSE STATEMENTS OR UNLAWFUL ACTS WILL RENDER MY COVERAGE NULL AND VOID. I AUTHORIZE PIE TO RELEASE PERSONALLY IDENTIFIABLE FINANCAIL INFORMATION AS APPLICABLE TO AFFILIATES AND NON-AFFILIATES DISCLOSED ON THE PIEPRIVACY STATEMENT FOR PURPOSES OF REINSURANCE PREMIUM CALCULATION, ETC.

Signature

Date

Page 1

RENEWAL FORM, PAGE 2

SUPPLEMENTAL QUESTIONS FOR DENTISTS WHO PROVIDE CONSCIOUS ORAL/ENTERAL SEDATION

YOU MUST CARRY PIE CLASS II COVERAGE IF YOU PROVIDE ENTERAL OR PARENTERAL SEDATION

Please list your drug(s) of choice and standard dosage regimen:
Are you using the following recommended monitoring device, etc?

Pulse oximeter

Yes Yes

No No NA

List Serial No. and Brand Name

Current emergency drugs

Yes Yes

No No NA

Positive pressure oxygen

Yes Yes

No No NA
Do all patients who undergo oral conscious sedation sign a written informed consent form specific for oral sedation that has been reviewed and approved by PIE?

Yes Yes

No No NA
Do you have patients complete a health history form within one week of a scheduled procedure that expresses no contraindications to the use of oral sedative agents?

Yes Yes

No No NA
Do you keep a supply of reversal drugs (e.g. Romazicon) available?

Yes Yes

No No NA
Do you log vital signs at specific intervals during the procedure?

Yes Yes

No No NA
Do you limit the oral sedation technique to patients over 18 and under 60 years old, or have you taken an advanced course on sedation for children and elderly pts?

Yes Yes

No No NA
When did you originally take an introductory course in anxiolytic drugs and oral sedation?

PIE requires you to take a refresher course every three years. Most recent date taken:

Furnish copy of initial or most recent course certificate.

No Yes NA

SUPPLEMENTAL QUESTIONS FOR DENTISTS WHO PERFORM THEIR OWN IV/IM/PARENTERAL SEDATION

NOTICE: YOU ARE NOT COVERED TO USE PROPOFOL AS PART OF YOUR IN-OFFICE IV SEDATION REGIMEN.

Are you in compliance with all equipment and monitoring requirements as specified in R156-69-601 of the Utah Practice Act, including

Pulse oximetry

Yes Yes

No No NA

Current emergency drugs

Yes Yes

No No NA

Positive pressure oxygen

Yes Yes

No No NA
Do all patients who undergo parenteral sedation sign an informed consent form specific for parenteral sedation that has been reviewed and approved by PIE?

Yes Yes

No No NA
Do you utilize a third person (besides you and your dental assistant) whose sole duty is to monitor the patient and record pertinent data during the procedure?

Yes Yes

No No NA
How many parenteral sedation cases do you expect to perform per month?

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT ANY FALSE STATEMENTS OR UNLAWFUL ACTS WILL RENDER MY COVERAGE NULL AND VOID

Name

Signature

Date

Page 2

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