Application attachments

We must have these attachments to process your application(s).

Required Equipment and Emergency Drugs form

Complete this form, as applicable. It's attached with the application.

Schedule and log of inspection (documented monthly inspection)

A copy of the schedule and log showing your regular inspection of all emergency drugs and equipment for the administration of anesthesia, sedation, and/or nitrous oxide-oxygen. Include the date(s) and name of the person who last checked the drugs and equipment, and the results of the checks. Include a statement that the condition of equipment meets manufacturers’ specifications.

Some applications also need these attachments

Proof of certifications

For each person in the facility administering anesthesia & sedation or assisting in the administration of anesthesia & sedation, we need copies of the following certifications:

• Advanced Cardiac Life Support (ACLS), or

• Pediatric Advanced Life Support (PALS), or

• Basic Life Support for Healthcare Providers (BLS)

Copies of forms and paperwork

Depending on the application, you may need to submit copies of the following:

• Your office’s medical history form to be completed by each patient

• Your office’s anesthesia monitoring chart

• Your office’s anesthesia consent form to be completed by each patient

• Your written protocol for the management of medical emergencies

• Your schedule and content of regular and routine office emergency drills

• Weekly spore testing results for the 3 months prior to your application

  • If your office has been open less than 3 months, submit:

    • The protocols and procedures for spore testing at the site

    • Any and all weekly spore testing results to date

• Your Federal DEA Controlled Substance Certificate

• Your MA Controlled Substance Registration

• Your request for an on-site inspection of the site by the Board

  • For permit D-A only:

    • You may submit instead a copy of the certificate of an on-site inspection conducted by the Massachusetts Society of Oral and Maxillofacial Surgeons (MSOMS members only). This must be from the past 5 years.

• Your DPH Radiation Control Program Certification (M.G. L. c. 111 §5N)

• All current individual anesthesia permits of your staff