Dental Support Organization Information {3801}

Form 3801--General Information (Dental Support Organization Registration) The attached form is designed to meet minimal statutory filing requirements pursuant to the relevant code provisions. This form and the information provided are not substitutes for the advice and services of an attorney. Commentary Dental Support Organizations (DSOs) are governed by Chapter 73 of the Texas Business & Commerce Code and the secretary of state's administrative rules found in 1 Texas Administrative Code Chapter 98. Section 73.004, Bus. & Comm. Code and 1 TAC §98.2 set forth the registration requirements for DSOs. This form is for both initial registrations as well as renewals. A registration is effective on the date the completed registration, applicable attachments and filing fee are received by the secretary of state. Registrations expire annually on December 31st and must be renewed by January 31st of each calendar year. Any changes to the information given on the registration must be filed with the secretary of state quarterly. Form 3805 may be used to update the information as necessary. Instructions for Form Preliminary Information: Select the appropriate box indicating whether this is an initial registration or renewal. For renewals, the registration number assigned by the secretary of state should be provided to facilitate processing of the document. DSO Information: The registration must set forth the DSO's legal name and business address and mailing address if different. Ownership Information: The registration must set forth the name and address of each person who owns 10% or more of the DSO. If the number of owners exceeds the space provided, please use the DSO Ownership Information Addendum (Form 3803). o A person under this section must identify as either a Dentist Owner or Non-Dentist Owner by checking the applicable box on the form. o A Dentist Owner is an individual licensed in this state to provide dentistry services who also owns 10% or more of the DSO. o A Non-Dentist Owner can be an individual or business entity that owns 10% or more of the DSO. If Non-Dentist Owner is selected and the person is an individual, the name of the individual should be completed. If Non-Dentist Owner is selected and the person is a business entity, the legal name of the entity should be completed. Business Support Services: Sec. 73.001 of the Bus. & Comm. Code defines "business support services" as business, management, consulting, or administrative services, facilities, or staff provided for a dentist, including: (A) (B) (C) (D) Form 3801 office space, furnishings, and equipment; staff employed by the dental support organization; regulatory compliance; inventory or supplies, including dental equipment and supplies; Instruction Page 1 ­ Do not submit with filing. American LegalNet, Inc. www.FormsWorkFlow.com (E) (F) (G) (H) (I) (J) (K) (L) information systems; marketing and advertising; financial services; accounting, bookkeeping, or monitoring or payment of accounts receivable; payroll or benefits administration; billing and collection for services and products; reporting and payment of federal or state taxes; administration of interest expense or indebtedness incurred to finance the operation of a business; or (M) insurance services. If a DSO provides two or more business support services to a dentist, the name of the dentist, the name of the professional entity or dental practice through which services are provided to a dentist, and the business address should be included. The business support services should be described in the box that follows. The dental support agreement determines the number and type of business support services provided. If the number of dentists exceeds the space provided, please use the DSO Business Support Services Addendum (Form 3804). As a ministerial filing office, the secretary of state cannot make a determination as to whether an activity constitutes a "business support service" under the statute. For assistance in determining whether a particular service meets this definition, please consult your private attorney. Execution: The registration must be signed by a person authorized to act by or on behalf of the DSO. Payment and Delivery Instructions: The filing fee for a DSO registration or renewal is $150. Fees may be paid by personal checks, money orders, LegalEase debit cards or American Express, Discover, MasterCard, and Visa credit cards. Checks or money orders must be payable through a U.S. bank or financial institution and made payable to the secretary of state. Fees paid by credit card are subject to a statutorily authorized convenience fee of 2.7 percent of the total fees. Attachments: The following items must be included with the registration: 1. DSO Contact Sheet (Form 3802); 2. Filing fee of $150; 3. Dental Support Organization Owner Information Addendum (Form 3803) and/or Dental Support Organization Business Support Services Addendum (Form 3804) as necessary. The completed form, along with the filing fee and necessary attachments may be mailed to Secretary of State, Registrations Unit, P.O. Box 13193, Austin, Texas 78711-3193 or delivered to the James Earl Rudder Office Building, 1019 Brazos, 1st Floor, Austin, Texas 78701. The secretary of state will issue a certificate of registration upon filing of a completed registration. Form 3801 Instruction Page 2 ­ Do not submit with filing. American LegalNet, Inc. www.FormsWorkFlow.com Form 3801 Rev. 04/2016 This space reserved for office use only Submit to: SECRETARY OF STATE Registrations Unit P O Box 13193 Austin, TX 78711-3193 512-475-0775 Filing Fee: $150 Initial Registration Renewal of Registration DENTAL SUPPORT ORGANIZATION REGISTRATION Registration Number: (Applicable for renewals only) Dental Support Organization Information Dental Support Organization (DSO) Name: Business Address (Please include street address, city, state and zip code): Mailing Address (if different from above): Ownership Information List each person who owns 10% or more of the DSO. For each person named, select either dentist owner or nondentist owner. See instructions for additional information. Include Dental Support Organization Ownership Information addendum (Form 3803) as necessary if number of owners exceeds space provided. Name: Dentist Owner: Non-Dentist Owner: Business Address (Please include street address or P.O. box, city, state and zip code): Name: Dentist Owner: Non-Dentist Owner: Business Address (Please include