Our dental office will be using Zoom remote communication technology to conduct problem focused evaluations/re-evaluations virtually, to help manage your oral health problem and to determine whether you have a condition that requires immediate in-office treatment.
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 provisions of medical or dental services using non-public facing audio or video remote communication services. Remote patient consultations may take place over applications that allow video charts such as Zoom, Apple Face Time, Facebook Messenger video chat, Google hangouts or Skype and may involve or be based on photos or videos taken with smart phones by the patient and transmitted to the dental office. Please do not contact us using public-facing services such as Facebook Live, Twitch, or TikTok, which are not permitted by the federal government for this purpose.
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 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 encrypted, which is one of the main HIPAA requirement that is being relaxed during the nationwide COVID-19 public health emergency.
Certain major dental plans have announced that they will reimburse dental offices for conducting such remote evaluations, and we will submit claims in connection with them.
Our dental office is using one or more of the permitted modalities listed above for remote transmission of information to conduct limited problem focused evaluations. While entirely adequate in the vast majority of cases for such limited purposes, these evaluations may not reveal conditions that would be discovered during an office visit or through the use of specialized teledentistry technology.
Please indicate your understanding of and informed consent to these terms, which will be in effect until the government rescinds its suspension of these HIPAA requirements, by typing your name in the space provided and return via email to this office.
I understand that this teledentistry is available under these pandemic conditions and that I am to seek further care, whether at LifeTime Dental or elsewhere when the pandemic is over.
ASSIGNMENT OF INSURANCE BENEFITS: I, as subscriber or insured, hereby assign to LifeTime Dental all dental and medical insurance benefits applicable to this admission and authorize my insurer or third party payment program to tender payment of such amounts directly to LifeTime Dental or its affiliates. I understand that I am responsible to pay LifeTime Dental or its affiliates all charges, co-payments or deductibles remaining after insurance payments and all LifeTime Dental charges and professional fees for services and supplies that are not paid for by my insurer or third party payor because they have been prospectively determined to be not covered by my insurance contract or third party payment program.
Please note: Should an accident / incident occur during an appointment, LifeTime Dental will not be held liable.
MY ACKNOWLEDGEMENT: I have been informed, understand, and give my consent to diagnostic procedures necessary to determine further emergency treatment options for my dental needs. I understand the dentist will not be physically present during my appointment. I understand that I have access to the dentist by phone, email or video conferencing.
CONSENT TO TREATMENT: I do hereby voluntarily consent to treatment by the dentists of LifeTime Dental (the “Practice”) for a dental exam and to any related diagnostic procedures and treatments as necessary in the judgment of the dentists of the Practice. I understand that the Practice is providing me a dental evaluation and a telehealth dental examination by a dentist.