Renewal Form 2019-10-15T01:53:49+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 
      NA 
      If not, you must carry PIE’s H-Rider.
    • Check if you do any of the following procedures:
      Yes 
        (Requires Class B permit with Dental License)
      Yes 
        (Requires. PIE Class II Coverage)
      Yes 
        (Req. PIE Class II Coverage)
      Those checking either category below must fill out questions on PAGE 2.
      Yes 
        (Req.Class D Anesth. Permit)
      Yes 
        (PIE Class II coverage + Class C Anesth. Permit)
      Yes 
        (PIE Class II coverage + Class D Anesth. 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 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

    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

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

      Pulse oximeter

      Yes 
      No  NA

      Current emergency drugs

      Yes 
      No  NA

      Positive pressure oxygen

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

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

      Yes 
      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 
      No  NA
    • 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 
      No  NA

      Current emergency drugs

      Yes 
      No  NA

      Positive pressure oxygen

      Yes 
      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 
      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 
      No  NA
    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

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