(A) The Ohio state dental board hereby prescribes that the written work authorization required in division (B) of section 4715.09 of the Revised Code shall be on printed forms for both original and copy and shall contain the following:
(1) The name and address of the entity or person to whom the written work authorization is directed, hereinafter referred to as "primary contractor".
(2) The patient's name and/or identifying number. In the event such identifying number is used, the name of the patient shall be written upon a copy of such written work authorization retained by the dentist.
(3) A description of the work to be done, with diagrams if applicable.
(4) A description of the type of the materials to be used.
(5) The actual date on which the authorization was written.
(6) The signature in ink by the dentist issuing the said written work authorization, his state dental license number and his office address.
(7) A section to be completed by the primary contractor and returned to the issuing dentist that shall disclose all of the following information and certify that the information is accurate by including the signature of a responsible party of the primary contractor:
(a) A list of all materials in the composition of the final appliance;
(b) The location where the appliance was fabricated, including the name, address, phone number and FDA registration number, if applicable, of the person or entity performing the work;
(c) The location, including name, address, phone number and FDA registration number, if applicable, of any sub-contractors utilized to perform some or all of the services relative to the fabrication of the appliance;
(d) A description of all disinfection methods used in the fabrication of the appliance.
(B) Upon request, the dentist shall provide each patient or authorized patient representative with a duplicate copy of the section of the form described in paragraph (A)(7) of this rule.
(C) The dentist shall retain a copy of the written work authorization for two years from its date as a part of the patient record.
(D) The primary contractor shall retain the original work authorization for two years from its date. Copies of work authorization forms shall be open for inspection by the Ohio state dental board and its investigators.
(E) If the primary contractor receiving a written work authorization from a licensed dentist engages another unlicensed person, partnership, association, or corporation (herein referred to as "sub-contractor") to perform some of the services relative to such work authorization, as provided for in division (C) of section 4715.09 of the Revised Code, he or it shall notify the issuing dentist in advance of the fabrication of the appliance of the name and location of the subcontractor and shall furnish a written sub-work authorization with respect thereto on forms prescribed by the state dental board.
The sub-contractor shall retain the sub-work authorization and the primary contractor shall retain a duplicate copy, attached to the work authorization received from the licensed dentist, for inspection by the state dental board or its duly authorized agents, for a period of two years. Copies of work authorization forms shall be open for inspection by the Ohio state dental board and its investigators.
(F) The foregoing does not prohibit the inclusion of additional information on the written work authorization when the same is necessary or desirable.
(G) "Unlicensed person, partnership, association or corporation" as used in this rule, includes, but is not limited to, dental laboratory or dental laboratory technician.
(H) "Appliance" as used in this rule, includes, but is not limited to, any denture, plate, bridge, splint, crown, veneer, or orthodontic or prosthetic dental device.