In an attempt to assist state dental boards I have taken the lead of the Kansas Board of Dentistry and created a form letter. This letter is available for download and can be customized as needed.
You can download the free “Prove It” document by clicking here.
If any boards need assistance in who should receive these letters, please email me, I would be more than happy to provide that information if available.
You are most welcome,
Debbie Hagan
PS. You may also copy and paste from this blog post:
Here is a form letter designed to assist state dental boards with investigations of corporate owned dental clinics operating under the disguised of being dentist owned clinics. Such as Aspen, Kool Smiles, Small Smiles, Dental Dreams, etc. It can be customized to fit your needs.
[State dental board letter head]
Dear Dr. [dentist name here]
The Dental Board requests [dentist’s name inserted here] provide a written response explaining how your association with [corporation name i.e. FORBA] corporation is not creating a violation of the dental practices act of the state of [enter name of state], specifically, [enter state practice act number and section forbidding or limiting corporate dentistry].
In the written response, we respectively request you provide all of the following:
1. A copy of your purchase agreement or ownership documents of the clinic.
2. An employee handbook.
3. A copy of advertisements published to hire dentists or other employees.
4. If a PC or LLC provide a list of all member with % of ownership interests. Include address and all contact information for the members and a full copy of your “Operating Agreement”.
5. An Operating Agreement or Contract between yourself and [enter the name of the corporation in question] showing the services they provide and the cost to your practice.
6. Attach your personal and business FEDERAL, STATE and LOCAL income tax returns with attachments, including Schedule C with W-2’s or 1099’s. If you are a PA, PC PLLC or LLC include returns for you personally and for the business entity.
7. Attach five payment reimbursement forms from Medicaid and five from insurance companies.
8. Attach copies of promissory notes or loan agreements with amortization schedule used.
9. Attach a copy of the last 6 bank account statements for the business.
10. Attach a copy of your last three Federal 941 forms and copies of checks included with Federal form 941. Include copies of checks if you made periodic payroll deposits. Include copies of the last three 941-V vouchers, if any.
11. Attach copies of your last three Federal 940 FUTA forms and copies of checks showing payments made.
12. Include copies of checks showing all of the following payments:
· Building and/or Equipment loan or leases
· Employee payroll
· Utilities
· Liability Insurance
· Malpractice Insurance and Workman’s Comp Insurance
· Insurance on building and/or equipment
13. Do you own the fixtures and equipment? ___ Yes ___No
If “No” state from whom it is leased:
Business Name:________________________
Contact Person: ________________________
Address:_______________________________
Telephone:_____________________________
If “Yes” include copies of checks showing local/state personal property tax.
14. Do you own the building? _____Yes ____No
If “No” state from whom it is leased:
Business Name:_________________________
Contact Person”_________________________
Address:_______________________________
Telephone:_____________________________
15. List dates of employment, names and contact information of all dentists, hygienists, and dental assistants employed by the clinic.
16. Provide a copy of your EIN application.
17. If you own or operate more than one clinic, provide the legal name and dba name of each clinics, as well as its physical location include ALL states.
Please add the following statement, sign and date:
“I attest the above to be a true and accurate statement including all attachments”
Provide the above information within ten(10) days from the receipt of this letter.
Sincerely,
[Signature of Investigator]
