Get Standing Order Template (pdf) - Mass

Completing the Standing Order Template (PDF) for Massachusetts is an important step for licensed dental hygienists working in public health settings. This guide provides clear instructions to help you navigate through each section of the form with confidence.

Follow the steps to accurately complete the standing order template.

1. Press the ‘Get Form’ button to access the Standing Order Template (PDF) and open it in your preferred PDF editor.
2. Fill in the 'Standing Order Declaration' section by entering the name of the licensed dental hygienist along with their credentials, ensuring all data is accurate and up-to-date.
3. In the 'Procedures to be provided' section, initials must be added by both the dental hygienist and the supervising dentist for each procedure listed, including oral screenings and fluoride applications.
4. Complete the 'Public Health Settings' section by providing detailed information for each facility where services will be offered, including the program name, type of facility, address, and phone number. Update this section throughout the year as needed.
5. Fill out the 'Parties to the Standing Order' section with both the dental hygienist and supervising dentist's details, including names, license numbers, addresses, and emergency contact information.
6. Describe specific program protocols in the respective section, detailing all operating procedures and responsibilities that the dental hygienist must adhere to under this standing order.
7. Outline the method for managing dental records, ensuring to address confidentiality, storage, and retrieval procedures within the relevant section of the form.
8. Detail emergency protocols that will be followed during service provision, emphasizing the importance of regular training and reviews of these protocols.
9. Complete the 'Attestations' section by having both the dental hygienist and supervising program dentist sign and date the document, confirming their agreement and understanding of the responsibilities involved.
10. After filling out all sections, review the completed form for accuracy. Save your changes, download the document, and print or share it as necessary.

Begin filling out your Standing Order Template online today and ensure compliance with Massachusetts regulations.