Fillable Form 3801General Information: (Dental Support Organization Registration) Commentary (Texas Secretary of State)

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Form 3801General Information: (Dental Support Organization Registration) Commentary (Texas Secretary of State)

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Form 3801 Instruction Page 1 – Do not submit with filing.
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 31
st
and must be renewed by January 31
st
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) office space, furnishings, and equipment;
(B) staff employed by the dental support organization;
(C) regulatory compliance;
(D) inventory or supplies, including dental equipment and supplies;
Form 3801 Instruction Page 2 – Do not submit with filing.
(E) information systems;
(F) marketing and advertising;
(G) financial services;
(H) accounting, bookkeeping, or monitoring or payment of accounts receivable;
(I) payroll or benefits administration;
(J) billing and collection for services and products;
(K) reporting and payment of federal or state taxes;
(L) 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, 1
st
Floor, Austin, Texas 78701. The
secretary of state will issue a certificate of registration upon filing of a completed registration.
Form 3801 1
This space reserved for office
use only
DENTAL SUPPORT ORGANIZATION
REGISTRATION
Form 3801
Rev. 04/2016
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 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 non-
dentist 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 street address or P.O. box, city, state and zip code):
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 street address or P.O. box, city, state and zip code):
Name: Dentist Owner: Non-Dentist Owner:
Business Address
(Please include street address or P.O. box, city, state and zip code):
Business Support Services Provided to Dentists
Identify each dentist licensed in the state with whom the DSO has entered into a dental support agreement to provide
two or more business support services and identify the type of business support services provided. Include Dental
Support Organization Business Support Services Addendum (Form 3804) as necessary if number of dentists exceeds
space provided.
Dentist Name:
Name of Professional Entity or Dental Practice:
Business Address
(Please include street address, city, state and zip code):
Describe all business support services provided:
Dentist Name:
Name of Professional Entity or Dental Practice:
Business Address
(Please include street address, city, state and zip code):
Describe all business support services provided:
Dentist Name:
Name of Professional Entity or Dental Practice:
Business Address
(Please include street address, city, state and zip code):
Describe all business support services provided:
Dentist Name:
Name of Professional Entity or Dental Practice:
Business Address
(Please include street address, city, state and zip code):
Describe all business support services provided:
Attachments
The following items are included with this registration
1. DSO Contact Sheet (Form 3802);
2. $150 filing fee;
3. Dental Support Organization Ownership Information Addendum (Form 3803) and/or Dental
Support Organization Business Support Services Addendum (Form 3804) as necessary.
Execution
Form 3801 3
Date: BY:
Signature of authorized person
Printed or typed name of authorized person
This space reserved for office
use only
DENTAL SUPPORT ORGANIZATION
CONTACT SHEET
Form 3802
Rev. 04/2016
Submit to:
SECRETARY OF STATE
Registrations Unit
P O Box 13193
Austin, TX 78711-3193
512-475-0775
The information on this page is used for contacting Dental Support Organizations during the registration review
process.
Dental Support Organization Name:
Contact Name:
Email Address:
Phone:
Mailing Address
(Please include street address or P.O. box, city, state and zip code):
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Form 3801General Information: (Dental Support Organization Registration) Commentary (Texas Secretary of State)

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Completed 6 November 2020

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