(a) Display in facility.

1. (1) The license (or a photocopy of the license) of each dentist or dental hygienist working in the mobile dental facility shall be prominently displayed in the facility.
2. (2) The permit to operate the mobile dental facility shall be prominently displayed in the facility.

(b) Consent forms.

1. (1) A consent form must be obtained prior to the provision of any dental service in a mobile dental facility.
2. (2) The form must be signed by the patient or by a parent or guardian if the patient is a minor or an incapacitated person.
3. (3) Written consent forms are required for the initial visit for diagnostic and preventive services.
4. (4) Consent for subsequent treatment may be written or verbal providing that the verbal consent is recorded and stored as a part of the dental record.

5. (5) A consent form must include at a minimum:

   1. (A) Name of dentist providing the service;
   2. (B) Permanent office address;
   3. (C) Telephone number that is available twenty-four (24) hours per day for emergency calls; and
   4. (D) Service or services to be provided.

6. (6)

   1. (A) If the patient is a minor, the consent form must also contain the following questions and statement: Has the child had dental care in the past twelve months? Yes No If yes, please list the name and address of the dentist or dental office where the care was provided. _______________________________ Does the child have an appointment scheduled at the dental home? Yes No “I understand that I can choose to have any or all dental treatment for my child at the dental home. I understand that all dental care provided by my dental home or a mobile dental facility may affect future benefits that the child may receive from private insurance, Medicaid (ArKids), or other third-party provider of dental benefits.”
   2. (B) If the patient is an adult, the consent form must be signed by the patient and contain the following statement: “I understand that I may choose at any time to receive care from my dental home rather than from the mobile dental facility.”
   3. (C) If the patient is an incapacitated person, the form must be signed by the patient’s legal guardian and contain the following statement: “I understand that I may choose at any time to take the patient to his/her dental home for dental care rather than from the mobile dental facility.”

(c) Post-care information to patients.

1. (1) Each person receiving dental care in a mobile dental facility must receive an information sheet at the end of the visit.

2. (2) The information sheet must contain:

   1. (A) Name of dentist or dental hygienist who provided the service;
   2. (B) Telephone number and/or other emergency contact number;
   3. (C) Listing of treatment rendered including, when applicable:

(i) Billing codes;

1. (ii) Fees; and

   1. (iii) Tooth numbers;
   2. (D) Description of treatment that is needed or recommended;
   3. (E) Referrals to specialists or other dentist if mobile facility is unable to provide the necessary treatment; and
   4. (F) Consent form or a recorded, verbal consent for additional treatment or altered treatment plan when applicable.