General Informed Consent for Treatment, Diagnosis, and Radiographs
Dear Prospective Patient,
Thank you for your interest in our services. Please read the following information and sign in the appropriate place.
MY ACKNOWLEDGEMENT: I have been informed, understand and give my consent to preventative dental treatment, diagnostic and radiographic procedures necessary to determine further comprehensive treatment options for my dental needs.
CONSENT TO TREATMENT: I do hereby voluntarily consent to treatment by the hygienists/dentists of Virtudent MA, LLC.,d/b/a Virtudent (the “Practice”) for a dental screening and preventative dental treatment, including a professional cleaning and x-rays and to any related diagnostic procedures and treatments as necessary in the judgment of the hygienists/dentists of the Practice, which may include dental sealants and fluoride varnish application. I understand that the Practice is providing me preventative dental care and a telehealth dental screening, which is not a substitute for a comprehensive dental examination by a dentist. I specifically consent to the taking or use of photographs/radiographs and the transmission of these images to provide telehealth dental screening services.
PUBLICATION OF RECORDS: Because I have sought treatment through Virtudent, a practice that leverages telehealth technologies and partners with educational institutions to provide high quality diagnoses and treatment plans, I authorize that records of my case, including progress notes, radiographs, photographs, slides, or any other available documentation be made available for third party educational/research/teaching purposes and/or insurance/reimbursement; every effort will be made to prevent my identity from being revealed. I expect no compensation or other remuneration, and I specifically release and agree to hold harmless Virtudent, any affiliated educational institutions, Virtudent’s agents, employees, faculty, and others from any liability or other obligation arising from the taking or use of photographs/radiographs and providing telehealth dental services. I further understand and intend that this release shall be binding on me, my heirs, executors, administrators, successors, and assigns.
EMAIL COMMUNICATION: I authorize Virtudent and its affiliates to communicate with me via encrypted email regarding my dental assessment including any diagnosis, follow-up report, x-rays and other medical health information at an email address provided by me. Given I have provided my email during the sign-up process, Virtudent can assume that email communications are acceptable to me.
ACCESS TO MEDICAL INFORMATION: I authorize Virtudent and its affiliates to (1) release my insurance company or third party payor or administrator any information they request from my medical/dental record in connection with their settlement of any claim filed for my case and any related review, including quality assurance and utilization reviews; (2) permit representatives of my insurer, third party payor or administrator to review my dental record either at Virtudent or its affiliated dental schools for the purposes of performing quality assurance and utilization reviews in connection with their review of my case; (3) release information requested from my dental record to other dentists, facilities or agencies in order to facilitate the provision of continuing care; and (4) permit affiliated and non-affiliated dental and scientific personnel to review my dental records from time-to-time for dental research purposes; Provided that any such review shall be made in a manner calculated to maintain the confidentiality of my identity.
ASSIGNMENT OF INSURANCE BENEFITS: I, as subscriber or insured, hereby assign to Virtudent 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 Virtudent or its affiliates. I understand that I am responsible to pay Virtudent or its affiliates all charges, co-payments or deductibles remaining after insurance payments and all Virtudent 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.
If you have questions or concerns regarding this consent form, please contact us at:
Phone Number: 877-487-4295
Email Address: info@myVirtudent.com
Mailing Address: 124 Vernon St. | Newton, MA 02458
By selecting yes in Denticon, I acknowledge receipt of this Notice of Privacy Practices and confirm that my electronic acceptance of this Notice is the legally binding equivalent to my handwritten signature.
IF THE PATIENT IS UNDER 18 YEARS OR INCOMPETENT TO CONSENT, a parent or legal guardian must contact Virtudent at 877-487-4295.