Collaborative Practice Agreement *
Collaborative Practice Dental Hygienist Information:
Michael R. United, RDH BA RF
12345 Everywhere Street
Anytown MN 55555
Phone: 555.555.5555 Home
666.666.6666 Work
777.777.7777 Cell
Email: rdh1_hygienist@website.com
Minnesota Dental Hygiene License Number: H0000
Collaborative Practice Dentist Information:
Mary J. Prevention, DDS
54321 Always Street
Anytown MN 55555
Phone: 888.888.8888 Work
999.999.9999 Cell
Email: dds1_dentist@website.com
Minnesota Dentist License Number: D0000
Identify all practice location(s) for the oral health care program:
1. ________insert name and address of school/center/facility here_____________________
123 West Street
Anytown MN 55555
2. ________insert name and address of additional school/center/facility here____________
Intended population to be served:
For a school/educational setting:
Children enrolled in __________ School, Anytown Minnesota, ages ___ to ___
For a Head Start Center or early childhood/pre-school setting:
Children enrolled in ________ Center, Anytown Minnesota, ages ___ to ___ and their
parents/guardians
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For a health care or long- term care/residential setting:
Residents of ____X____ Nursing Home/Facility, Anytown Minnesota
(Best Practices:) Describe the population, e.g. low income, uninsured, underinsured, special needs,
geriatric, medically fragile, etc.)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
(Best Practices):
Include the name, title and credentials of the person authorized to represent ____x______
school/center/facility; (include address if different from above):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Intended services to be provided:
Head Start, early childhood/pre-school setting:
Assurance of “consent” for treatment; medical history review; anticipatory guidance;
oral health education/instruction; hard and soft tissue assessment/triage;
dietary/nutritional assessment; fluoride varnish (~3 months); referral for further
diagnosis and/or treatment services as needed; recommended recall frequency.
School/educational setting:
Assurance of “consent” for treatment; medical history review; anticipatory guidance;
oral health education/instruction; hard and soft tissue assessment/triage;
dietary/nutritional assessment; fluoride varnish (~3 months); determination for and
placement of dental sealants; referral for further diagnosis and/or treatment services as
needed; recommended recall frequency;
Health care or long-term care/residential setting:
Assurance of “consent” for treatment; medical history review/determination of “medically
compromised” status requiring consultation with dentist or physician; oral health
education/instruction with client or care giver; hard and soft tissue assessment/triage; dental
hygiene treatment plan to include caries risk assessment; health education/disease
management; radiographs; anticipatory guidance on dietary/nutritional and tobacco use
factors; determination of periodontal status to determine treatment plan of prophylaxis vs.
scaling/root planing; determination of need for local anesthesia; removable
prosthesis/denture cleansing; fluoride varnish (~3 months); recommendation of recall
frequency; referral for further diagnosis, comprehensive treatment plan and/or treatment
services as needed.
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CPR for the Health Care Provider: (Best Practices): Attach copy of CPR card
Date Taken: _______________
Through Which Association (e.g. AHA, ARC) _________________________________________
Recertification Due Date: ________________________________________________________
Medical emergencies continuing education course:
(Best Practices): attach copy of CE course completion certificate
Date attended: ________________________________________________________________
Program Sponsor: ______________________________________________________________
Infection control continuing education course:
(Best Practices): attach copy of CE course completion certificate
Date attended: ________________________________________________________________
Program Sponsor: ______________________________________________________________
Dental Hygienist professional liability insurance coverage:
(Best Practices: attach copy of recent policy renewal)
Name of Insurance Company: ____________________________________________________
Address of Insurance Company: __________________________________________________
__________________________________________________
__________________________________________________
Policy Number: _______________________________________________________________
Patient records will be held at the following location:
Name of school/center/facility/office/home:
_____________________________________________________________________________
_____________________________________________________________________________
Address of school/center/facility/office/home:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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(Best Practices):
Describe the protocol to be used that will assure security of hard-copy/paper patient records, in
particular in regard to storage (e.g. locked cabinet?) and transport (locked box?) between the
site and office; will duplicate copies of records be made? If electronic dental records are to be
utilized, describe the security process for electronic transfer of patient records; what steps will
be taken to assure secure networks.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Compensation for treatment services:
(Best Practices):
Describe how the reimbursement for services provided by the dental hygienist will be handled:
e.g. will the dental hygienist be working in an “employer/employee” relationship; has the
dental hygienist declared a non-profit employment status; describe how the billing and
payment-for-services protocol will be handled, to include insurance filing, sliding fee scale, copayments, pro-bono; state if the program is grant funded and if so, identify which parts of the
program are to be covered by the grant, which parts are covered by other means, etc.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
MN Medicaid/National Provider Identifier (NPI) number:
Dental Hygienist ________________________
Dentist: ______________________________
Program supplies:
(Best Practices):
Describe how the acquisition of and payment for program supplies will be handled, e.g. include
protocol for acquisition of items requiring a prescription, e.g. fluoride, anti-microbial rinses:
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
______________________________________________________________________________
Attachments:
* Consent to Care/Informed Consent Form
* Age and procedure-specific treatment protocols
* Notice of time period for examination by a dentist, including the statement “Procedures
provided by the collaborative practice dental hygienist DO NOT substitute for a
comprehensive examination by a dentist.”
* Referral form, to include recall frequency
* Protocol for treating medically compromised patients to include conditions when a dentist
evaluation and treatment plan must occur prior to provision of services by the dental
hygienist
Signature of Dental Hygienist entering the Collaborative Agreement:
____________________________________________________Date: _____________________
Signature of Dentist entering the Collaborative Agreement:
____________________________________________________Date: _____________________
(Best Practices):
Signature of person authorized to represent Anytown Minnesota school/center/facility_____
___________________________________________________Date: _____________________
Registration of this collaborative agreement with the Minnesota Board of Dentistry occurred
on: Date: _____________________________________________________________________
Collaborative agreement annual renewal/review occurred on:
Dental Hygienist signature: _____________________________________________________
Date: _______________________________________________________________________
Dentist signature: _____________________________________________________________
Date: _______________________________________________________________________
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Additional notes:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Note: The “Best Practices” notations in this document are not required per MN Statute 150.10,
subd.1a., Limited Authorization for Dental Hygienists or MN Rules. These sections are suggested
to be included in a collaborative agreement document as clarifying statements.
* (this template is offered as an example, i.e. the exact format is not required)
Template revised May 2013 C. Larkin
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