Anesthesia Evaluations

Description of Program

The In Office Anesthesia Evaluation Program established by the PSOMS has been providing anesthesia evaluation services for the Pennsylvania State Board of Dentistry since 2004. The program’s primary purpose is to evaluate candidates interested in obtaining an anesthesia permit that allows them to provide anesthesia services to patients undergoing in-office dental and surgical treatment. The program is designed to allow a candidate to demonstrate, in real time in front of evaluators highly trained in anesthesia care, their didactic knowledge and clinical skills by providing anesthesia care to a patient undergoing dental treatment. The program also evaluates the facility in which the anesthesia services are provided to ensure that all systems, ancillary equipment, monitors, supplies, medications, protocols and anesthesia care team involved with providing anesthesia services are the safest, most up to date and demonstrate a high standard of care. INSTRUCTIONS FOR INITIAL ANESTHESIA PERMIT APPLICANTS A) If you are a First Time Applicant for an anesthesia permit you must follow these instructions as written below: I. First Apply for a “Request For Provisional Approval” from the Pennsylvania State Board of Dentistry as a first step in obtaining the 1-day Provisional Anesthesia Permit. This Application can be obtained in one of three ways:

1) Go to the Pennsylvania State Board of Dentistry web site at


b) Under BOARD RESOURCES click on General Board Information

c) Under BOARD FORMS AND RESOURCES click on Initial Applications

d) Under INITIAL APPLICATIONS click on Dentist

e) Select the Anesthesia Permit (Unrestricted or Restricted 1) form for which you are applying

f) Mail the completed application and all the necessary documentation required to the address on the form

2) Contact the Pennsylvania State Board of Dentistry by calling 1-717-783-7162 and request the Provisional Anesthesia Permit Application form for the level you desire.

3) Mail your request for a Provisional Anesthesia Permit Application indicating the level of permit you desire directly to the Pennsylvania State Board of Dentistry at:

State Board of Dentistry P.O. Box 2649 Harrisburg, PA 17105-2649

II. The State Board of Dentistry will review the application making sure all the documentation requested is included, and they will then send you a Request for A Provisional Permit Form. THIS IS NOT THE 1 DAY PROVISIONAL ANESTHESIA PERMIT. III. After you have received this form from the State Board of Dentistry you must:

A) Email this form without signing to indicating that you are requesting the Application for An Anesthesia Evaluation be sent to you. Once the Request for Provisional Approval is received the application forms will be emailed to you. This is different than what you did for the State Board of Dentistry.

IV. After you have received the application information (this is a 37 page document which includes information helping you prepare for your evaluation) complete the required 4 pages as indicated in the instructions making sure they are signed and witness where indicated. Email only the 4 required forms (and not the entire file) with a copy of a check made payable to PSOMS Anesthesia in the amount of $200.00 to Please mail the check to the following address noting that the check is for your anesthesia evaluation: PSOMS PO Box 500 Harrisburg, PA 17108 – 500 Once the application forms and proof of payment have been received, the application forms will be sent to the Regional Director for your geographic area to set up the anesthesia evaluation. You will be then be contacted by the Regional Director to arrange the date of the Office Anesthesia Evaluation. V. Once this date has been scheduled, you must record this date on the Request for a Provisional Permit Form that you received previously from the Pennsylvania State Board of Dentistry and return the form to and also upload the completed form to your application on PALS. . DO NOT RETURN THIS FORM TO THE PSOMS. VI. The SBOD requires the Executive Director to send a letter with a copy of the completed form confirming the evaluation date. VII. The State Board will then send Dr. Robbins and the applicant your Provisional Permit for only that date. PLEASE NOTE!!! YOUR PROVISIONAL PERMIT WILL ONLY BE VALID FOR THE ONE (1) DAY NOTED ON THAT FORM. Please call Dr. James L. Robbins at 215-394-7284 at least 2 days before the evaluation if you have not received the 1-day Provisional Anesthesia Permit by that time. VIII. Please call Dr. James L. Robbins with any questions or concerns before your inspection. Do not wait until the last minute!!!!