I am acknowledging that I wish to receive a teledentistry consultation with my dentist. In the absence of radiographs (x‐rays), I understand that I may be asked to send photographs or other documentation as requested by the dentist. I will try to provide as much detailed information as I can. I understand that the doctor is limited to what they are able to determine in these circumstances. I also understand that if I am experiencing pain or swelling that is life threatening, I will call 911 or go to an emergency room.
Certain major dental plans have announced that they will reimburse dental offices for conducting remote evaluations, and we will submit claims in connection with them. I understand that I am responsible for any payment resulting from this consultation that is not covered by a dental insurance plan. In addition, I understand and consent to this consultation being recorded for clinical documentation and accuracy.
HIPAA: During the current pandemic the federal government announced that it will not enforce HIPAA regulations (privacy for health records) in connection with medical and dental offices’ good faith provision of medical or dental services using non-public facing audio or video remote communications services. Remote patient consultations will take place over HIPAA compliant GoToMeeting and may involve or be based on photos or videos taken with smart phones by the patient and transmitted to the dental office. As always, our office will take dental record confidentiality very seriously, and will do what we can under the circumstances to protect the information you send to us. While we believe the risk to such confidentiality is not high, it may be greater than it would be if these remote electronic communications were fully encrypted end-to-end, which is one of the main HIPAA requirements that is being relaxed during the nationwide COVID-19 public health emergency.