(b) The information sheet must contain:

1. (1) Name of the:

   1. (A) Collaborative care dental hygienist who provided the service; and
   2. (B) Consulting dentist;
2. (2) Telephone number and/or other emergency contact number of the dental hygienist and consulting dentist;

3. (3) Listing of treatment rendered including, when applicable:

   1. (A) Billing codes;
   2. (B) Fees; and
   3. (C) Tooth numbers;

4. (4)

   1. (A) Description of further treatment that is needed or recommended.
   2. (B) The dental hygienist will advise the patient and/or legal guardian that dental hygiene services:

(i) Are preventive in nature; and

1. (ii) Do not constitute a comprehensive dental diagnosis.

   1. (C) The dental hygienist will:

      1. (i) Recommend that patients see the consulting dentist; or
      2. (ii) Give a list of dentists within a fifty-mile radius for comprehensive care; and
2. (5) The collaborative dentist is ultimately responsible for the care of the patient.