Notification Form for Closing or Transferring Ownership of a Practice: The Alberta College of Dental Hygienists

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The below form is a requirement for dental hygienists who are closing or transferring ownership of a practice they own or operate.

As per College Bylaws:

At least 90 days prior to opening, operating, acquiring, adding a component to, or moving a dental hygiene practice, a regulated member is required to provide written notification to the College of the following information:

(a) the practice name;
(b) phone number;
(c) email address;
(d) complete business address;
(e) names of any additional owners;
(f) any other information requested by the Registrar.

A regulated member is required to provide written notification to the College of any change in the ownership interests or changes to information listed in (1) above at least 90 days prior to the anticipated change.

Any regulated member who closes or transfers ownership of a dental hygiene practice is required to provide written notification to the College of the closure or transfer at least 90 days prior to the anticipated date.

Please complete and submit this form.

First Name of Owner/Operator *

Last Name of Owner/Operator *

Registration Number of Owner/Operator *

Email address *

This will be the email address we use to communicate with you about your dental hygiene practice.

Is there more than one owner/operator of this practice? *

Yes

No

If you responded Yes to the above question, please provide full name(s) and registration number(s), if applicable. Any additional business owners/operators who are registered dental hygienists must complete this form in full and submit it separately.

Additional Owners/Operators

Reason for completing Bylaw form *

Closing a practice

Transferring ownership of a practice

Business name of dental hygiene practice *

Phone Number *

Practice Setting (check all that apply) *

Standalone - Store front

Standalone - Home based

Mobile

Mobile Van

Other

If you responded Other to the above question, please provide a description of the practice setting.

Anticipated date of the above event *

Have you read the Continuity of Care Standards of Practice and Guidelines and do you understand how they relate to the closure or transfer of ownership of a business? *

Yes

No

Have you provided reasonable notice to patients to ensure they can continue their care with a dental hygienist or another oral health care provider? *

Yes

No

Identify what steps you have taken to ensure continuity of care for your patients: (Check all that apply.) *

I have provided my patients with my new practice location.

I have provided options for alternate oral health care providers to continue my patients' care.

Other

If you responded Other to the above question, please provide a description of the steps you have taken.

What safeguards are in place to ensure the security of patient records? *

Will patient records will be retained for a minimum of 10 years following the date of the last service provided or, in the case of minor patients, until the patient is 20 years of age or for 10 years, whichever is longer? *

Yes

No

How will patients access their records for the duration of the retention period? *

Please provide the address where patient records will be stored upon closing or ownership transfer of the business. *

If you answered No to any of the above multiple choice questions on continuity of care, reasonable notice to patients, or patient records, please provide more information.

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