Nebraska Admin. Code Title 172, Ch. 56-004
Temporary License: Dentist
During a disaster, public health emergency, or other period of need, an individual who holds an active license to practice dentistry in another state can apply for and obtain a dental locum tenens from the Division of Public Health of the Department of Health and Human Services, and may practice for up to 90 days per year in Nebraska.
LICENSURE OF DENTISTS AND DENTAL HYGIENISTS
56-004 DENTAL LOCUM TENENS: A dental locum tenens may be issued by the Department, with the recommendation of the Board, to an individual who holds an active license to practice dentistry in another state when circumstances indicate a need for the issuance of a dental locum tenens in the State of Nebraska. A Dental locum tenens may be issued for a period not to exceed 90 days in any 12-month period. 56-004.01 Circumstances for which a dental locum tenens license may be issued: 1. The unavailability of a Nebraska dentist due to vacation, sickness or hospitalization or other similar leaves of absence; 2. A public health emergency in the State of Nebraska such as one arising from incidents of widespread disease, natural or manmade disaster or similar causes; or 3. For volunteer dental services such as the Mission of Mercy Program. 56-004.02 To receive a dental locum tenens, an individual must meet the following qualifications: 1. Age and Good Character: Be at least 19 years old and of good character; 2. Citizenship/Lawful Presence Information: For purposes of Neb. Rev. Stat. §§ 4-108 to 4-114, be a citizen of the United States or qualified alien under the Federal Immigration and Nationality Act. For purposes of Neb. Rev. Stat. § 38-129, be a citizen of the United States, an alien lawfully admitted into the United States who is eligible for a credential under the Uniform Credentialing Act, or a nonimmigrant lawfully present in the United States who is eligible for a credential under the Uniform Credentialing Act. 3. Holds an active license to practice dentistry in another state if the requirements regarding education and examination for licensure in that state are equal to or exceed the requirements regarding education and examination for licensure in Nebraska. 56-004.03 Application: To apply for a dental locum tenens, the individual must submit a complete application to the Department. The applicant may obtain an application from the Department or construct an application that must contain the following information: 1. Written Application: a. Personal Information: (1) The legal name of the applicant, maiden name (if applicable), and any other names by which the applicant is known; (2) Date of birth (month, day, and year); (3) Place of birth (city and state or country if not born in the United States); (4) Mailing address (street, rural route, or post office address; and city, state, and zip code, or country information); (5) The applicant's: (a) Social Security Number (SSN); (b) Alien Registration Number ("A #"); or (c) Form I-94 (Arrival-Departure Record) number. Certain applicants may have both a SSN and an A # or I-94 number, and if so, must report both. (6) The applicant's telephone number including area code (optional); (7) The applicant's e-mail address (optional); (8) The applicant's fax number (optional); b. Education: Name and location of the applicant's accredited dental program; c. Indicate whether or not the applicant holds a Federal Drug Enforcement Administration (DEA) Registration; d. Practice Before Application: The applicant must state: (1) That s/he has not practiced dentistry in Nebraska before submitting the application; or (2) If s/he has practiced dentistry in Nebraska before submitting the application, the actual number of days practiced in Nebraska before submitting the application for a credential and the name and location of practice; and e. Answer the following questions either yes or no. For any yes answers, explain the circumstances and outcome. Applicant will be notified of any additional documentation which is required by the Board/Department: Section I (1) Have you ever had any disciplinary or adverse action imposed against a professional credential or permit in any state or jurisdiction? (2) Have you ever voluntarily surrendered or voluntarily limited in any way a credential or permit issued to you by a licensing or disciplinary authority? (3) Have you ever been requested to appear before any licensing agency? (4) Have you ever been notified of any charges, complaints or other actions filed against you by any licensing or disciplinary authority? (5) Are you aware of any pending disciplinary actions or of any on-going investigations of a complaint against your credential or permit in any jurisdiction? (6) Have you ever been asked to and/or permitted to withdraw an application for licensure or permit with any Board or jurisdiction? (7) Has any state or jurisdiction refused to issue, refused to renew or denied you a credential or permit to practice? Section II (1) Are you currently, or have you ever been, addicted to, dependent upon or chronically impaired by alcohol, narcotics, barbiturates, or other drugs which may cause physical and/or psychological dependence? (2) Within the past 5 years, have you received any therapy/treatment or been admitted to any hospital or other in-patient care facility for reasons relating to your use/abuse of alcohol, narcotics, barbiturates, or other drugs? (3) Do you currently, or have you ever had, any physical, mental, or emotional condition which impaired, or does impair your ability to practice your health care profession safely and competently? (4) Within the past 5 years, has any licensing agency or credentialing organization initiated any inquiry into your physical, mental or emotional health. Section III (1) Have you ever been restricted, suspended, terminated, requested to voluntarily resign, placed on probation, counseled, received a warning or been subject to any remedial or disciplinary action during dental school or postgraduate training? (2) Have you ever had hospital or institutional privileges denied, reduced, restricted, suspended, revoked, terminated or placed on probation? (3) Have you ever voluntarily resigned or suspended hospital or institutional privileges while under investigation from a hospital, clinic, institution, or other dental related employment? (4) Have you ever been notified that any action against your hospital or institutional privileges is pending or proposed? (5) Have you ever been allowed to withdraw your staff privileges from a hospital or institution? (6) Have you ever been subject to staff disciplinary action or non-renewal of an employment contract? Section IV (1) Have you ever been convicted of a felony? (2) Have you ever been convicted of a misdemeanor? (3) Have you ever been notified of any charges, complaints or other actions filed against you by any criminal prosecution authority? Section V (1) Have you ever been denied a Federal Drug Enforcement Administration (DEA) Registration or state controlled substances registration? (2) Have you ever been called before any licensing agency or lawful authority concerned with DEA controlled substances? (3) Have you ever surrendered your state or federal controlled substances registration? (4) Have you ever had your state or federal controlled substances registration restricted or disciplined in any way? Section VI (1) Have you ever been notified of any professional liability claim that resulted in an adverse judgment, settlement, or award, including settlements made prior to suit in which the patient releases any professional liability claim against the applicant? (2) Are you aware of any professional liability claims currently pending against you? f. Attestation: The applicant must attest that: (1) S/he has read the application or has had the application read to him/her; (2) All statements on the application are true and complete; (3) S/he is of good character; (4) S/he has not committed any act that would be grounds for denial under 172 NAC 56-007 or if an act(s) was committed, provide an explanation of all such acts; and (5) S/he is: (a) For purposes of Neb. Rev. Stat. §§ 4-108 to 4-114, a citizen of the United States or qualified alien under the Federal Immigration and Nationality Act; and (b) For purposes of Neb. Rev. Stat. § 38-129: (i) A citizen of the United States; (ii) An alien lawfully admitted into the United States who is eligible for a credential under the Uniform Credentialing Act; or (iii) A nonimmigrant lawfully present in the United States who is eligible for a credential under the Uniform Credentialing Act. 2. Documentation: The applicant must submit the following documentation with the application: a. Evidence of age, such as: (1) Driver's license; (2) Birth certificate; (3) Marriage license that provides date of birth; (4) Transcript that provides date of birth; (5) U.S. State identification card; (6) Military identification; or (7) Other similar documentation; b. Evidence of good character, including: (1) Other Credential Information: If the applicant holds or has held a credential to provide health services, health-related services, or environmental services in Nebraska or in another jurisdiction, the applicant must submit the state, credential number, type of credential, date issued, and expiration date of each credential. The applicant must have the licensing agency submit to the Department a certification of his/her credential; (2) Disciplinary Action: A list of any disciplinary actions taken against the applicant's credential and a copy of the disciplinary action(s), including charges and disposition; (3) Denial: If the applicant was denied a credential or denied the right to take a credentialing examination, an explanation of the basis for the denial; (4) Conviction Information: If the applicant has been convicted of a felony or misdemeanor, the applicant must submit to the Department: (a) A list of any misdemeanor or felony convictions; (b) A copy of the court record, which includes charges and disposition; (c) Explanation from the applicant of the events leading to the conviction (what, when, where, why) and a summary of actions the applicant has taken to address behaviors/actions related to the conviction; (d) All addiction/mental health evaluations and proof of treatment, if the conviction involved a drug and/or alcohol related offense and if treatment was obtained and/or required; (e) A letter from the probation officer addressing probationary conditions and current status, if the applicant is currently on probation; and (f) Any other information as requested by the Board/Department. c. Evidence that the applicant is: (1) For purposes of Neb. Rev. Stat. §§ 4-108 to 4-114, a citizen of the United States or qualified alien under the Federal Immigration and Nationality Act; and (2) For purposes of Neb. Rev. Stat. § 38-129, a citizen of the United States, an alien lawfully admitted into the United States who is eligible for a credential under the Uniform Credentialing Act, or a nonimmigrant lawfully present in the United States who is eligible for a credential under the Uniform Credentialing Act. d. Evidence of citizenship, lawful presence, and/or immigration status may include a copy of: (1) A U.S. Passport (unexpired or expired); (2) A birth certificate issued by a state, county, municipal authority or outlying possession of the United States bearing an official seal; (3) An American Indian Card (I-872); (4) A Certificate of Naturalization (N-550 or N-570); (5) A Certificate of Citizenship (N-560 or N-561); (6) Certification of Report of Birth (DS-1350); (7) A Consular Report of Birth Abroad of a Citizen of the United States of America (FS-240); (8) Certification of Birth Abroad (FS-545 or DS-1350); (9) A United States Citizen Identification Card (I-197 or I-179); (10) A Northern Mariana Card (I-873); (11) A Green Card, otherwise known as a Permanent Resident Card (Form I-551), both front and back of the card; (12) An unexpired foreign passport with an unexpired Temporary I-551 stamp bearing the same name as the passport; (13) A document showing an Alien Registration Number ("A #"). An Employment Authorization Card/Document is not acceptable; or (14) A Form I-94 (Arrival-Departure Record); e. Certification of license from a state in which applicant holds a current license; f. Official Documentation requesting the issuance of a dental locum tenens permit for the purpose of replacing a dentist who will be unavailable for a specific period of time, or for volunteer dental services such as the Mission of Mercy Program.