By signing this form or by verbal consent, I understand the following:
1. I wish to engage in a teledentistry consultation with the Bala Kids Dentistry team.
2. I understand that the use of teledentistry is a way to provide care for people who cannot go the dental office. Teledentistry uses electronic dental records such as previous x-rays in an existing patient’s records, photographs or recordings of the condition of your teeth, health, and other health history information to the absolute best of the provider’s ability.
3. I understand that the laws that protect privacy and the confidentiality of medical information also apply to teledentistry, and that no information obtained in the use of teledentistry which identifies me will be disclosed to researchers or other entities without my consent.
4. Bala Kids Dentistry team member has explained to me how the audio/video conferencing technology will be used. I am aware that this type of consultation will not be the same as a direct dentist/patient visit due to the fact that I will not be in the same room as the dental practitioner.
5. I understand that a face-to-face consultation with the dentist may still be necessary after the teledentistry appointment. This could be because of my specific dental or medical condition. Recommendations will be made about my future dental care after the teledentistry consultation.
6. I understand that there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties.
7. I understand that the Bala Kids dentistry team member or I can discontinue the teledentistry consult/visit if it is felt that the videoconferencing connections are not adequate for the situation
8. I understand that teledentistry may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state if deemed necessary.
9. I understand that Bala Kids Dentistry information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider. All people who may be present will maintain confidentiality of the information obtained
10. I understand that it is my duty to inform my dentist of electronic interactions regarding my care that I may have with other healthcare providers.
11. I understand that I may expect the anticipated benefits from the use of teledentistry in my care, but that no results can be guaranteed or assured.
12. I understand that there are charges based on duration of the time consultation and documentation of the teledentistry consultation. These charges may or may not be covered by my insurance company and I take responsibility to pay those charges to Bala Kids Dentistry. Therefore, the initial fee for a teledentistry consultation is $45 and payment is expected at the time of service.
13. I understand that my insurance company will be charged if applicable and acceptable by them, and I may be financially responsible for full or partial payment of any non-covered or partially covered services. I realize that it is my responsibility to contact my individual insurance carrier to ensure that teledentistry services are covered.
14. I have made the choice to participate in a teledentistry consultation. I assume the risk of the limitations set forth herein, and I further understand that no warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.