Get Compliance With Best Management Practices For Dental Offices ...

This guide provides detailed instructions for completing the Compliance With Best Management Practices For Dental Offices Certification Form online. By following these steps, dental practitioners can ensure their practices adhere to the necessary regulations regarding mercury amalgam.

Follow the steps to successfully complete the certification form.

1. Press the ‘Get Form’ button to access the certification form and open it in your preferred online editor.
2. In Part I, select the appropriate category that describes your role: Dental Practitioner/Owner, Exempt Dental Practitioner/Owner, or Non-Practicing Licensed Dentist. This selection determines which parts of the form you need to complete.
3. Complete Part II by providing the name of your practice or clinic, the street address, city or town, state, zip code, business phone, and fax number. Also provide the owner of the practice and their license number.
4. If there are multiple owners, check the corresponding box and be sure to list additional owners in Part V.
5. For Non-Practicing Licensed Dentists, fill out Part III with the required personal information including name, license number, address, and contact details.
6. In Part IV, list all amalgam separation units present in your practice, including their manufacturer, model, serial number, and installation date.
7. In Part V, provide the names and license numbers of all other licensed dentists practicing at your clinic, indicating if any are owners.
8. Sign and date the certification statement in Part VI. Dental Practitioners/Owners and Exempt Dental Practitioners/Owners must complete Part VI A. Non-Practicing Licensed Dentists and Dental Practitioner/Non-Owners complete Part VI B.
9. Once all parts are completed and signed, save the form as needed. You can then download, print, or share the completed certification form.
10. Mail the signed, original Certification Form to the specified address: Central Permit Processing Unit - Mercury Program, Connecticut Department of Environmental Protection, 79 Elm Street, Hartford, CT 06106-5127.

Take the next step in maintaining your practice's compliance by completing the Certification Form online today.