section .0800 – special restricted licenses

21 NCAC 16B .0801          TEMPORARY VOLUNTEER DENTAL PERMIT

(a)  An applicant for a temporary volunteer dental permit shall submit to the Board an application form provided by the Board at www.ncdentalboard.org that includes the following information:

(1)           full name;

(2)           street address;

(3)           employer name and address, and the applicant's position title;

(4)           work, home, and cellular telephone numbers;

(5)           fax number;

(6)           email address;

(7)           any other name by which the applicant was known in the past;

(8)           social security number;

(9)           citizenship or immigration status, with verifying documentation;

(10)         authorization to work in the United States;

(11)         dental education, including dental school name, address, and the applicant's graduation date, and any other dental post-graduate education;

(12)         all dental licenses from other states ever held by the applicant, including state, license number, date issued, and licensure status as of the application date;

(13)         if the applicant has ever been denied a license or the privilege of taking a dental licensure or competency examination by any dental licensing authority or examining body, a written statement disclosing the details, jurisdiction, and date;

(14)         if the applicant is not engaged in the practice of dentistry as of the application date, the last month and year when the applicant practiced;

(15)         if the applicant has been charged with or convicted of any crime within the 10 years preceding the application date, excluding traffic violations but including driving while impaired offenses, a written statement disclosing the details and copies of the charges and judgment;

(16)         if the applicant has any contagious or infectious disease, a written statement disclosing the details;

(17)         a statement disclosing and explaining any current condition or impairment, including substance abuse, alcohol abuse, or a mental, emotional, or nervous disorder or condition, that in any way affects the ability to practice dentistry. For purposes of this Rule, "current" means recently enough that the condition may affect the applicant's ability to function as a dentist as set out in G.S. 90-41(a)(2) and (7). If the applicant contends that the condition or impairment is reduced or ameliorated because the applicant is receiving ongoing treatment or participating in a monitoring or support program, the applicant may provide information regarding the treatment or program, and may include any verification demonstrating that the applicant has complied with all provisions and terms of any drug treatment program, or impaired dentists or other impaired professionals program;

(18)         the type of facility and addresses of all facilities where the applicant will provide temporary volunteer dental services in North Carolina;

(19)         the dates on which the applicant intends to provide temporary volunteer dental services in North Carolina;

(20)         the names of all North Carolina licensed dentists who will direct or supervise the applicant at each location where the applicant will provide temporary volunteer dental services;

(21)         a copy of an unexpired CPR certificate;

(22)         a photograph of the applicant taken within six months preceding the application date;

(23)         a completed fingerprint record card and signed release of information form authorizing the Board to request a fingerprint-based criminal history record check from the North Carolina State Bureau of Investigation (SBI); and

(24)         a signed, notarized statement by the applicant affirming the applicant has not been disciplined by any dental board or agency, the information in the application is accurate, and no fee will be charged or accepted for any dental services provided.

(b)  In addition to the requirements of Paragraph (a) of this Rule, the applicant shall request the applicable entity or person to send the following required information or documents to the Board office, with each document in an unopened envelope sealed by the entity involved:

(1)           a statement from all jurisdictions in which the applicant is now or has ever been licensed, disclosing the applicant's disciplinary history and current status of the applicant's license; and

(2)           a statement signed by a North Carolina licensed dentist agreeing to provide supervision or direction to the temporary volunteer dentist, stating when and where the supervision or direction will occur and affirming that no fee or monetary compensation of any kind will be paid to the applicant for dental services performed.

(c)  The Board shall receive all items set forth in Paragraphs (a) and (b) of this Rule for the application to be complete. Applications that are not completed within one year of being submitted to the Board shall be disregarded as expired.

(d)  The holder of a temporary volunteer dental permit shall notify the Board within five days of any changes in the practice location or facility disclosed under Paragraph (a) of this Rule.

(e)  To renew the temporary volunteer dental permit, the licensee shall submit to the Board:

(1)           an affidavit or notarized statement verifying the location and type of facility where the applicant will practice, the duration of the practice, the name of the supervising dentist, that no fee will be charged or accepted, and that the information in the original application submitted under Paragraph (a) of this Rule is correct and requires no update or correction; and

(2)           the information required in Paragraph (b) of this Rule.

The Board shall receive all items set forth in this Paragraph for the renewal application to be complete before the deadline for renewing applications. The applicant shall report any changes to submitted information within five days of when the licensee knew or should have known of the changes.

(f)  Any applicant who changes his or her address shall notify the Board office in writing within 10 business days.

(g)  Any license obtained through fraud or by any false representation shall be revoked.

History Note:        Authority G.S. 90-29; 90-37.2; 90-41;

Eff. February 1, 2008;

Amended Eff. September 1, 2014;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 9, 2018;

Amended Eff. March 1, 2020.