Aspen Dental Virtual Care Terms & Conditions
*Virtual Care is offered in CT, NH, AL, IA, LA, MN, OR, PA, VT, NM, FL, GA, IL, IN, MO, NY, TN.
By utilizing this service, I hereby request, consent and authorize Aspen Dental practices, their respective subsidiaries, affiliates, representatives, and agents (collectively, “Aspen Dental Virtual Care” or “ADVC”) and their employed or contracted Dentists or other licensed dental professionals in its care network (the “Practitioners”), to utilize teledentistry through ADVC’s proprietary systems, methods and protocols to access, diagnose, consult, treat and educate me and those I am authorized to represent (the “Services”).
I acknowledge and consent to see a Practitioner via teledentistry. I understand that my eligibility to receive a visit via teledentistry is based on the Practitioner’s clinical judgment that it is appropriate and that the quality of care will not be diminished by the use of teledentistry. I understand that a teledentistry visit is distinct from an in-person visit because I will not be in the same room as the dental Practitioner, and instead, I will communicate with the Practitioner through advanced communication technology using live video and audio feed.
I acknowledge that in order to protect my privacy, I need to choose a private location to place my teledentistry call. I understand that in order to provide the best call environment, I should reduce background light from windows or light emanating from behind me. I understand that my camera should be placed on a secure, stable platform to avoid wobbling and shaking during the teledentistry session. To the extent possible, my camera should be placed at the same elevation as my eyes with my face clearly visible to the other person. I understand that I will be informed of the presence of any third party, including those that may be present to assist with the audio or video equipment, and that I have the right to: (1) omit specific details of medical history or physical examination that are sensitive to me during such third party presence, (2) ask non-medical personnel to leave the teledentistry examination room, and/or (3) terminate the consultation at any time by notifying the Practitioner or disconnecting from the teledentistry portal.
I understand the potential risks of receiving the Services via teledentistry include: delays in dental evaluation due to technological equipment failure, a lack of access to all relevant information, or a security breach allowing unauthorized access to my confidential healthcare information. I understand that my Practitioner or I may terminate the teledentistry visit at any time, including if the Practitioner or I feel that an in-person visit is necessary for any reason. I have had the Services and alternatives to teledentistry for my Services explained to me and I choose to and continue with a teledentistry visit.
I understand that any complaint may be filed with the Secretary of the Department of Health and Human Services.
I have read and understood the written information provided above. I agree that the information provided above adequately explains the Services, along with the risks and benefits to me of said Services. I have had the opportunity to ask questions about this information – if I had any questions, all of my questions have been answered in full. By electronically signing this form, I acknowledge and agree to all of the above, and certify that I have no questions and/or have had my questions answered in full.
By electronically signing this informed consent, I am agreeing to conduct transactions electronically, and intend for my electronic signature to be a binding electronic signature on myself and those I am authorized to represent. Further, I understand and acknowledge that I am digitally receiving a copy of this Agreement concurrently upon execution to print and/or retain a copy of this Agreement, and may also request a paper copy from ADVC using the contact information below:
Aspen Dental's HIPAA Compliance Officer may be reached at 800-996-6470 extension 201250.
TERMS OF SERVICE
By using the websites and/or the virtual care platforms made available for you hereby, you expressly agree to these Terms and Conditions. If you do not agree to these Terms and Conditions, you should immediately cease all use of and access to all of the websites and platforms. Please print a copy of these Terms and Conditions for your records.
IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL “911” IMMEDIATELY.
You will be connected to a board-certified dentist licensed in the state in which you are currently located; however, interactions with the Providers via the service are not intended to take the place of your relationship with your regular dentist or health care practitioners. You and the Provider are solely responsible for all information and/or communication sent during a video and/or telephone consultation or other communication. Providers on the platform may refuse care based on their independent clinical judgement and potential misuse of services.
ADVC does not guarantee that a video and/or telephone consultation is the appropriate course of treatment for a particular health care problem. The virtual consult is solely based on the information provided by you and, in the absence of a physical evaluation, the Provider may not be aware of certain facts that may limit or affect his or her assessment or diagnosis of your condition and recommended treatment. By accessing this platform, you agree to contact your dentist or physician immediately should your condition change or symptoms worsen. If you require urgent care, you should contact local emergency services immediately.
Neither ADVC, nor any of its subsidiaries or affiliates or any third party who may promote the service or provide a link to the service, shall be liable for any professional advice obtained from a Provider via the service or for any other information obtained on the website. ADVC does not endorse any specific tests, physicians, medications, products or procedures that are recommended by Providers that may use ADVC to communicate with you.
Hours of Operation / Availability: ADVC does not operate 24/7/365. Please note days and hours or operation posted at https://www.aspendental.com/virtualcare. ADVC operates in accordance with federal and state laws, rules and regulations and may not be available in certain states.
Payment: ADVC accepts credit cards, FSA/HSA debit cards and valid dental insurance for payment. If your dental insurer does not cover virtual care, you are responsible for the cost of the ADVC virtual consult.
Children: ADVC is not intended for use by children under the age of 18. If you are under the age of 18, you may only use the ADVC services with the direct involvement of a parent or guardian.
Electronic Communications: When you use ADVC, you are communicating with us electronically. You consent to receive communications from us electronically, including via text, email, and other communications from your desktop or mobile device. You agree that (a) all agreements and consents can be signed electronically and (b) all notices, disclosures, and other communications that we provide to you electronically satisfy any legal requirement that such notices and other communications be in writing.
Service Provider: ADVC utilizes a platform administered by Doxy.me.
Site Access, Security and Passwords: If you create a subscriber account for ADVC using the Doxy.me site, you agree to complete the registration process by providing current, complete, and accurate information as required by Doxy. You are responsible for all activities that occur under your account. In the event access to the Site or a portion thereof is limited requiring a user ID and password (“Protected Areas”), you agree to access Protected Areas using only your user ID and password as provided to you by Doxy. You agree to protect the confidentiality of your user ID and password, and not to share or disclose your user ID or password to any third party. You agree that you are fully responsible for all activity occurring under your user ID. Your access to the Site may be revoked by Doxy at any time with or without cause.
User Information: If you submit, upload, post or transmit any health information, medical history, conditions, problems, symptoms, personal information, consent forms, agreements, requests, comments, ideas, suggestions, information, files, videos, images or other materials to us (“User Information”), you agree not to provide any User Information that (1) is false, inaccurate, defamatory, abusive, libelous, unlawful, obscene, threatening, harassing, fraudulent, pornographic, or harmful, or that could encourage criminal or unethical behavior, (2) violates or infringes the privacy, copyright, trademark, trade dress, trade secrets or intellectual property rights of any person or entity, or (3) contains or transmits a virus or any other harmful component. You represent and warrant to ADVC and its Providers that you have the legal right and authorization to provide all User Information to ADVC and its Providers for use as set forth herein and required by ADVC and the Provider.
THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
Our Legal Duty
Your Aspen Dental practice ("we", "our", "us"), like all other medical and dental practices, is required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice went into effect April 14, 2003, with the latest revision August 20, 2013 and will remain in effect until modified or replaced. We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us according to the means outlined in this notice.
Uses and Disclosures of Health Information
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician/dentist, dental auxiliaries, students and other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose health information to notify,or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up prescriptions, dental supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services: We may use Patient Information internally to offer goods and services we believe may be of interest. We may use Patient Information to contact you to inquire or survey about the Patient experience at the location(s) visited and the prospect of future services or improvements needed to continue as your services provider. We may also create and use aggregate Patient Information that is not personally identifiable to understand more about the common traits and interests of our Patients.
We may utilize one or more third-party service providers to send email or other communications to you on our behalf, including Patient satisfaction surveys. These service providers are prohibited from using your email address or other contact information for any purpose other than to send communications on our behalf.
It is our intention to only send email communications that would be useful to you and that you want to receive. When you provide us with your email address as part of the registration or appointment setting process, we will place you on our list of patients to receive informational and promotional emails. In addition, patients and visitors to our website are given the opportunity to "opt-in" to receive electronic promotional communications by selecting the option to receive promotional email from us on our website.
Each time you receive a promotional email, you will be provided the choice to "opt-out" of future emails by following the instructions provided in the email or you can "opt-out" at any time by following the instruction provided.
- Measure usage of various pages on our website to help us make our information more pertinent to your needs and easy for you to access; and,
- Provide functionality such as online appointing, bill paying and other functionality that we believe would be of interest and value to you.
Fund Raising: We will not use your health information for fund raising activities without your written consent.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose, to authorized federal officials, health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. We may charge a fee for producing dental records and x rays as allowed by law.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). When you pay in full outside of your insurance plan for services you may request that we restrict this information and not disclose it to your healthcare plan or insurer.
Breach Notification: We will provide you with notification of a breach of unsecured PHI as required by law.
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. This request must be in writing. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. This request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.
Electronic Notice: If you received this notice on our Web site or by electronic mail (e-mail), you are also entitled to receive this notice in written form.
Questions and Concerns
If you would like additional information about our privacy practices or have questions, Aspen Dental's HIPAA Compliance Officer may be reached at 800-996-6470 extension 201250.
If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we made about access to your health information or our handling of your response to a request you made to amend or restrict the use or disclosure of your health information, or to have us communicate with you by alternative means or at alternative locations, you may send your concerns to Aspen Dental, Attn: HIPAA Compliance Officer 281 Sanders Creek Parkway East Syracuse, NY 13057.You also may submit written concerns to the U.S. Department of Health and Human Services. We will provide you with the address to the U.S. Department of Health and Human Services upon request.
We support your right to maintain the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
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