Informed Consent for Teledentistry Services
• I understand that teledentistry is the use of electronic information and communication
technologies by a dental provider used to deliver services to an individual when he/she is
located at a different location or site than I am. I understand this is done through a two-
way video link-up whereby the provider and assistant can see my image on the screen
and hear my voice
• I know there are potential risks with the use of this new technology. These include but
are limited to: Interruption of the audio/video link. , Disconnection of the audio/video link,
Electronic tampering, Or a picture that is not clear enough to meet the needs of the
• If any of these risks occur, the consultation might need to be stopped.
• I understand that the laws that protect privacy and the confidentiality of medical
information including (HIPPA) also apply to teledentistry.
• I understand that I have the right to withdraw my consent to the use of teledentistry in
the course of my care at any time, without effecting my right to future care or treatment in
• I can ask that the teledentistry and/or videoconferencing be stopped at any time.
• I fully understand the purpose for this teledenistry consult is to access and treat my
• I understand that by agreeing to this consent that I am consenting to receive
health care services via Teledentistry.
This notice describes how Medical/Dental information about you may be used and disclosed and how you
can get access to this information. Please read it carefully.
We understand that the privacy of your personal information is important to you. As your Dental office,
we believe your right to privacy is a fundamental part of your treatment: as such, we want you to
understand our privacy practices and procedures. Should you have any questions regarding these policies
please do not hesitate to call the office at (575) 524-7645.
Information We Collect About You: We collect personal information about you and your family's part
of your new patient process, during the course of your care, and from other health care entities you utilize
such as, other Dentists and specialist, imaging facilities, laboratories and your insurance company. This
personal information includes items such as your name, address, phone number, birth date, social security
number, employer, health history, insurance policy and coverage information and any information you
provide. During the course of your treatment we will collect Dental information regarding diagnosis,
treatment plans, progress and any test results or films.
How your Information Is Used: The personal and health information gathe4red may be used and
disclosed with your general consent for purposes of treatment, payment or routine healthcare operation.
This means we may send your information to other Dentists or facilities involved in your treatment as
well as to your insurance company or a collection agency to obtain payment. Any time with a written
request, Las Cruces Dental Solutions does not sell patient information to marketing or pharmaceutical
companies. In certain cases of public health interests, we may be required to disclose certain information
to local, state or national health organizations or government agencies. We may request to reach you via
email or a form of electronic messaging which is not encrypted. This means a third party may be able to
access the information and read it since it is transmitted over the internet. In addition, once the email is
received by you, someone may be able to access your email account and read it. By signing this
agreement, you understand the risk of a non encrypted email and hereby grant permission to sent patient
medical information via email unless you requested otherwise. We may contact you to provide
appointment reminder or information about treatment.
Safeguarding Your Personal and Health Information: We are required by law to (1) make sure that
personal and health information to only those employees who require the information to complete their
jobs and provide quality service to you.
Las Cruces Dental Solutions maintains physical, electronic and procedural safeguards to comply with
state and federal regulations that guard you personal and health information.. If you feel you privacy has
been violated, you have the right to file an complaint with the Department of Health and Human Services.
The complaint in no way influences your course of treatment with Las Cruces Dental Solutions.
the front desk prior to the effective date of any changes.
Your Right to Restrict Use of Information