Renewal Form 2019-07-03T23:03:24+00:00

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.
  • or
  • Do you use Sargenti Technique/N2 Paste?

    Yes 
    No 
    If so, you must use PIE Informed. Cons.
  • Do your hygienists give local anesthetics?

    Yes
    No 

    If so, do they have their own coverage?

    Yes
    No 
    If not, you must carry PIE’s H-Rider.
  • Check if you do any of the following procedures:
    Nitrous Oxide Analgesia 
      (Requires Class II permit with Dental License)
    In-office IV sedation provided by other professional 
      (Requires. PIE Class II Coverage)
    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.
    *In-office IV/IM sedation provided by you personally 
      (Req.Class III Anesth. Permit)
    *Oral/enteral conscious sedation with drugs other than Valium or Vistaril 
      (Requires PIE Class II Coverage + Class II Anesthesia Permit)
  • Are you currently CPR Certified?

    Yes
    No

    Up to date on required CE Hours?

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

    Yes
    No
  • AFTER LICENSE RENEWAL IN 2018, PLEASE ATTACH A COPY OF YOUR UPDATED DENTAL LICENSE.
    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

Page 1

RENEWAL FORM, PAGE 2

    If you use Valium or Vistaril or nitrous oxide only for sedation you do not need to fill out this form

    SUPPLEMENTAL QUESTIONS FOR DENTISTS WHO PROVIDE CONSCIOUS ORAL/ENTERAL SEDATION

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

  • Are you using the following recommended monitoring device, etc?

    Pulse oximeter

    Yes 
    No 

    Current emergency drugs

    Yes 
    No

    Positive pressure oxygen

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

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

    Yes 
    No 
  • 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 
    No 
  • Furnish copy of Course Attendance Certificate.

    PIE requires you to take a refresher course every three years


    SUPPLEMENTAL QUESTIONS FOR DENTISTS WHO PERFORM THEIR OWN IV/IM/PARENTERAL SEDATION
  • 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 
    No 

    Current emergency drugs

    Yes 
    No 

    Positive pressure oxygen

    Yes 
    No 
  • 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 
    No 
  • 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 
    No 
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

Signature

Page 2