Pursuant to Board Regulation 30, all facilities, in which an advanced anesthesia permit holder provides sedation services, must have an onsite inspection.  In order to apply for a facility inspection, please complete the following forms and send to the Board's offices.  

1. Mississippi Application for Facility Inspection

2. Mississippi Attestation Form

3. Self-Audit Checklist.  You must use the checklist below that corresponds with the Class of your Advanced Anesthesia permit.  (Please note, if you utilize an Anesthesiologist or CRNA for your sedation services, your facility must be permitted at a Class I level.)

Class I Checklist

Class II Checklist

Class III Checklist

4. A Mississippi Non-Permitted Provider Registration Form must be submitted with all applications when the services of a non-dental anesthesia provider is used. 

Mississippi Non-Permitted Provider Form

Once these forms are received, a Board staff member will contact you to schedule your onsite inspection.  Every initial inspection requires two permit holders to perform the inspection.  Date and times will be preselected based on permit holder schedules and you will be notified of the time and date for your inspection.