The SBDE Questionnaire- Update

We have heard from so many of you on the SBDE questionnaire. So, here's the update:

1) The language on the SBDE website has changed. Unless you are renewing your license, the questionnaire is voluntary! 

2) This questionnaire was developed by the Board in response to the passing of HB 3201 (text of the bill here)

3) Scroll Down to see the full questionnaire- so you can be prepared with the information. The purpose of the bill and the survey is to identify the practices and companies and DSOs providing dental care in Texas. Currently the Board has very limited information on the actual practices and locations of where dentistry is provided in the state. 

 

SBDE Questionnaire

 

1. What is your first name? *This question is required.

 

2. What is your last name? *This question is required.

 

3. What is your license number? *This question is required.

 

4. What is your email address? *This question is required.

 

5. What specialty certifications do you hold? (Check all that apply) *This question is required.

  •  None
  •  Dental Public Health
  •  Endodontics
  •  Orthodontics
  •  Oral & Maxillofacial Surgery
  •  Oral & Maxillofacial Radiology
  •  Oral & Maxillofacial Pathology
  •  Pediatric Dentistry
  •  Periodontics
  •  Prosthodontics

6. Do you provide dental services in the State of Texas? *This question is required.

  •  Yes
  •  No

7. Do you own all or part of a dental practice in Texas?

For the purpose of this question, an owner of a dental practice is a licensed dentist who has possession of any equity in capital, stock or profits of a dental practice. Examples may include, but are not limited to (1) a sole proprietor, (2) a general partner, or (3) a shareholder, officer or director of any business or professional organization. *This question is required.

  •  Yes
  •  No

8. How many dental practice locations do you own?

You will be required to fill out a dental practice location detail page for each location.

9. What is the name of the dental practice location?

 

10. What is the street address of the dental practice location?

 

11. What is the city of the dental practice location?

 

12. What is the zip code of the dental practice location?

 

13. What services do you provide at this location? (Check all that apply)

  •  General Dentistry
  •  Orthodontics
  •  Endodontics
  •  Pediatric Dentistry
  •  Prosthodontics
  •  Periodontics
  •  Oral & Maxillofacial Surgery
  •  Other Please enter an 'other' value for this selection.  

14. What is the name of the dental practice location?

 

15. What is the street address of the dental practice location?

 

16. What is the city of the dental practice location?

 

17. What is the zip code of the dental practice location?

 

18. What services do you provide at this location? (Check all that apply)

  •  General Dentistry
  •  Orthodontics
  •  Endodontics
  •  Pediatric Dentistry
  •  Prosthodontics
  •  Periodontics
  •  Oral & Maxillofacial Surgery

 

19. Do you employ dentists?

  •  Yes
  •  No

 20. How many dentists do you employ? You will be required to fill out an employed dentist detail page for each dentist. *

 

21. What is the employed dentist's first name?

 

22. What is the employed dentist's last name?

 

23. What is the employed dentist's license number?

 

24. What specialty certifications does the employed dentist hold?

  •  None
  •  Dental Public Health
  •  Endodontics
  •  Orthodontics
  •  Oral & Maxillofacial Surgery
  •  Oral & Maxillofacial Radiology
  •  Oral & Maxillofacial Pathology
  •  Pediatric Dentistry
  •  Periodontics
  •  Prosthodontics

25. Do you own all or part of a Dental Service Organization that provides services in Texas?

For the purpose of this question, an owner of a dental service organization is a licensed dentist who has possession of any equity in capital, stock or profits of a dental service organization. Examples may include, but are not limited to (1) a sole proprietor, (2) a general partner, or (3) a shareholder, officer or director of any business or professional organization.

For the purpose of this question, a dental service organization is an entity that: (1) per an agreement, provides clinical services or non-clinical business or management services to a dentist or dental practice or (2) employs or otherwise contracts with a dentist in the dentist's capacity as a dentist.

  •  Yes
  •  No

26. How many Dental Service Organizations do you own? You will be required to fill out a Dental Service Organization detail page for each organization.

 

27. What is the name of the Dental Service Organization?

 

28. What is the street address of the Dental Service Organization?

 

29. What is the city of the Dental Service Organization?

 

30. What is the zip code of the Dental Service Organization?

 

31. How many dental practice locations do you provide dental services to? You will be required to fill out a dental practice location detail page for each location.

 

32. What is the name of the dental practice location?

 

33. What is the street address of the dental practice location?

 

34. What is the city of the dental practice location?

 

35. What is the zip code of the dental practice location?

 

36. Are you a party to a Dental Service Agreement?

For the purpose of this question, a Dental Service Agreement is an agreement between a dental service organization and a dentist under which the dental service organization will:

(1) provide clinical services or non-clinical business or management services to a dentist or dental practice or

(2) employ or otherwise contract with a dentist in the dentist’s capacity as a dentist.

  •  Yes
  •  No

37. With how many Dental Service Organizations have you entered into a dental service agreement with? You will be required to fill out a dental service agreement detail page for each agreement. *

 

38. What is the name of the Dental Service Organization?

 

39. What is the street address of the Dental Service Organization?

 

40. What is the city of the Dental Service Organization?

 

41. What is the zip code of the Dental Service Organization?

 

42. What service does the dental service agreement provide for? (Check all that apply)

  •  Your Employment in Your Capacity as a Dentist
  •  Your Agreement to Provide Services in Your Capacity as a Dentist
  •  The Dental Service Organization's Performance of Non-Clinical Services
  •  The Dental Service Organization's Performance of Clinical Services
  •  Other Please enter an 'other' value for this selection.  

43. Are you a participating provider under the Medicaid program operated under Chapter 32, Human Resources Code?

  •  Yes
  •  No

44. Are you a participating provider in the Children's Health Insurance Program (CHIP) operated under Chapter 62, Health and Safety Code?

  •  Yes
  •  No

 

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Thank you for reporting the requested information. You will not be required to submit another survey until your next renewal date.

The completion of this survey, does not constitute completion of your annual license renewal.  In order to complete your renewal, you may return to the Dental Board's website to renew online.