P R A C T I C E R E S O U R C E S

Dental Services Group® | 146 2ND Street North, Saint Petersburg, FL 33702

TABLE OF CONTENTS

• What Constitutes A Dental Emergency?

• ADA Covid-19 Coding and Billing Interim Guidance

• NADL Are Dental Laboratories Considered Essential Or Non-

Essential Under New Ordinances?

• ADA Guide to Understanding and Documenting Teledentistry

Events

• NADL Covid-19 Resources

SAMPLE FORMS

• Sample Essential Employee Template for Critical Business

• COVID-19 Pandemic Emergency Dental Treatment Consent

Form

• Dental Patient Consent Form

• Employee Consent Form

What Constitutes a Dental Emergency?

Dental emergencies are potentially life threatening and require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain or infection, and include:

• Uncontrolled bleeding• Cellulitis or a diffuse soft tissue bacterial

infection with intra-oral or extra-oral swelling that potentially compromise the patient’s airway

• Trauma involving facial bones, potentially compromising the patient’s airway

Other urgent dental care:

• Extensive dental caries or defective restorations causing pain• Manage with interim restorative

techniques when possible (silver diamine fluoride, glass ionomers)

• Suture removal• Denture adjustment on radiation/

oncology patients• Denture adjustments or repairs when

function impeded• Replacing temporary filling on endo access

openings in patients experiencing pain• Snipping or adjustment of an orthodontic

wire or appliances piercing or ulcerating the oral mucosa

Urgent dental care focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments. These should be treated as minimally invasively as possible.

• Severe dental pain from pulpal inflammation• Pericoronitis or third-molar pain • Surgical post-operative osteitis, dry socket dressing changes• Abscess, or localized bacterial infection resulting in localized

pain and swelling• Tooth fracture resulting in pain or causing soft tissue trauma• Dental trauma with avulsion/luxation• Dental treatment required prior to critical medical procedures• Final crown/bridge cementation if the temporary restoration is lost,

broken or causing gingival irritation

Routine or non-urgent dental procedures includes but are not limited to:

• Initial or periodic oral examinations and recall visits, including routine radiographs• Routine dental cleaning and preventive therapies• Orthodontic procedures other than those to address acute issues (e.g. pain,

infection, trauma)

• Extraction of asymptomatic teeth• Restorative dentistry including treatment of asymptomatic carious lesions • Aesthetic dental procedures

The ADA recognizes that state governments and state dental associations may be best positioned to recommend to the dentists in their regions the amount of time to keep their offices closed to all but emergency care. This is fluid situation and those closest to the issue may best understand the local challenges being faced.

DENTAL EMERGENCYThis guidance may change as the COVID-19 pandemic progresses. Dentists should use their professional judgment in determining a patient’s need for urgent or emergency care.

DENTAL NON EMERGENCY PROCEDURES

FOR THE LATEST UPDATES, VISIT ADA.ORG/VIRUS

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This is evolving guidance and will be modified as more information becomes available. VERSION: March 21, 2020

The American Dental Association (ADA) recognizes the unprecedented and extraordinary circumstances dentists and their patients face. Our guiding principles are to mitigate transmission while also supporting emergency care for patients so as to help prevent overwhelming hospital emergency departments over the next three weeks. Under these circumstances, while some services will continue to be performed in dental offices, the ADA recognizes that patients would be best served when telecommunication technology can be leveraged to support dental care.

The ADA had previously disseminated guidance on use of the teledentistry codes. (D9995 and D9996 – ADA Guide to Understanding and Documenting Teledentistry Events). The following guide is intended to help dental offices navigate issues related to coding and billing for virtual appointments during the current COVID-19 pandemic.

Coding For services rendered in a dental office:

If you see a patient during the current COVID-19 quarantine environment the services you render in the office should be coded and billed per your current office routines.

For services rendered using telecommunication technology:

If you are providing care using telecommunication technology to triage patients or offer an evaluation to determine if the situation is urgent or emergent, then the following CDT codes can be used to document and report the services in the patient’s record and to a third party payer.

Oral Evaluations:

D0140 limited oral evaluation – problem focused

An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately. Definitive procedures may be required on the same date as the evaluation.

Typically, patients receiving this type of evaluation present with a specific problem and/or dental emergencies, trauma, acute infections, etc.

D0170 re-evaluation – limited, problem focused (established patient; not post-operative visit)

Assessing the status of a previously existing condition. For example:

- a traumatic injury where no treatment was rendered but patient needs follow-up monitoring;

- evaluation for undiagnosed continuing pain;

- soft tissue lesion requiring follow-up evaluation.

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D0171 re-evaluation – post-operative office visit

Case Management:

D9992 dental case management – care coordination

Assisting in a patient’s decisions regarding the coordination of oral health care services across multiple providers, provider types, specialty areas of treatment, health care settings, health care organizations and payment systems. This is the additional time and resources expended to provide experience or expertise beyond that possessed by the patient.

Teledentistry:

When you are providing services in a teledentistry environment one or the other of the following codes would be reported in addition to those cited above –

D9995 teledentistry – synchronous; real-time encounter

Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.

D9996 teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review

Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.

Frequently Asked Questions What is teledentistry?

Telehealth refers to a broad variety of technologies and tactics to deliver virtual medical, health, and education services. Telehealth is not a specific service, but a collection of means to enhance care and education delivery. Teledentistry refers to the use of telehealth systems and methodologies in dentistry. Teledentistry can include patient care delivery using, but not limited to, the following modalities:

• Live video (synchronous): Live, two-way interaction between a person (patient, caregiver, or provider) and a provider using audiovisual telecommunications technology.

• Store-and-forward (asynchronous): Transmission of recorded health information (for example, radiographs, photographs, video, digital impressions and photomicrographs of patients) through a secure electronic communications system to a practitioner, who uses the information to evaluate a patient’s condition or render a service outside of a real-time or live interaction.

• Remote patient monitoring (RPM): Personal health and medical data collection from an individual in one location via electronic communication technologies, which is transmitted to a provider (sometimes via a data processing service) in a different location for use in care and related support of care.

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• Mobile health (mHealth): Health care and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and personal digital assistants (PDA).

For more information: D9995 and D9996 – ADA Guide to Understanding and Documenting Teledentistry Events

Can I use my smart-phone or a video conferencing service like Skype? What about text messages and emails?

Telephones that have audio and video capabilities are appropriate for virtual evaluations. During the COVID-19 public health emergency, Office for Civil Rights (OCR) will not impose penalties for HIPAA noncompliance against health care providers that serve patients in good faith through certain everyday communications technologies. Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications.

• DO NOT USE public-facing technologies (examples): Facebook Live, Twitch, and TikTok. • CAN USE (examples): Apple FaceTime or Skype, Facebook Messenger video chat, Google

Hangouts video

Regarding emails and text messages, the OCR Notification does not address email and text communication. HIPAA does not prohibit using email or text communications, but a dental office that wishes to communicate with patients this way must conduct a written risk analysis and implement reasonable and appropriate safeguards. For some examples of safeguards contact dentalbenefits@ada.org

I am hearing that my insurance company stopped processing claims. Is this true?

Many dental benefit administers have required their staff to work remotely to conform to national guidelines requiring communities to mitigate transmission of COVID-19. ADA has been informed that claims submitted electronically are more likely to be processed on time and offices with Electronic Fund Transfer (EFT) capability will likely receive payment on time. Any transactions that involve paper processing will take longer under these extenuating circumstances.

Can I perform a problem focused evaluation on a new patient?

Yes. During these times, there could be patients looking for dental care and may find you through the ADA’s Find-A-Dentist tool or the benefit plan’s provider directory. The ADA recommends that you offer assistance to these patients. Please note that a benefit through their plan may be dependent on the payer’s policies. If you need assistance with claims please contact dentalbenefits@ada.org

Preventive procedures such as prophylaxis and fluoride varnish applications are covered “once every 6 months” rather than “twice an year”. Can the frequency limitations be standardized to twice a year to allow some flexibility as we reschedule patients?

The ADA is looking into this issue as of this writing and will provide an update at a later date.

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HIPAA & Telecommunication Technology The Centers for Medicare & Medicaid Services (CMS) and the Office for Civil Rights (OCR) issued guidance regarding HIPAA and use of telecommunication technology during the COVID-19 public health emergency that includes the following information:

OCR Guidance:

A covered health care provider that wishes to use audio or video communication technology to provide telehealth to patients during the COVID-19 nationwide public health emergency is permitted to use any non-public facing remote communication product that is available to communicate with patients. OCR is exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency. This exercise of discretion applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19. Full guidance

CMS Guidance:

Currently, CMS allows for use of telecommunications technology that have audio and video capabilities that are used for two-way, real-time interactive communication. For example, to the extent that many mobile computing devices have audio and video capabilities that may be used for two-way, real-time interactive communication they may qualify as acceptable technology. The new waiver in Section 1135(b) of the Social Security Act explicitly allows the Secretary to authorize use of telephones that have audio and video capabilities for the furnishing of Medicare telehealth services during the COVID-19 PHE. In addition, effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through certain everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency, but not those that are public facing such as Facebook Live, Twitch, and TikTok. Full guidance

Billing The ADA has been reaching out to third party payers to determine their policies with regards to payment for services rendered using telecommunication technology. Below is the information we have collected thus far. The ADA has also been following guidance being issued by CMS de-regulating telehealth and offering benefits for virtual check-ins as a means to support primary care. We are exploring if this guidance applies to dental care.

The ADA advises that all patient encounters using telecommunication technology continue to be appropriately documented in the patient’s record including date/time/duration of encounter, reasons for such encounter and associated clinical notes.

As of 5 PM CENTRAL March 20, 2020 [will be updated daily during this public health emergency]

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Payer Information as received by the ADA:

Would plans you administer benefit teledentistry consultations for limited and problem-focused evaluations? (D0140, D0170, D0171)?

Would plans you administer benefit a consultation with the patients’ physician? (D9311)

Will frequency limits be waived to not count towards evaluations that may be needed later in the year when D0140, D0170 and D0171 are submitted?

Aetna

Will reimburse for it when performed via teledentistry, same as if it is performed in a traditional practice setting. We cover D0140 and D0170 today. We do not currently cover D0171. We do not offer a separate benefit for the two teledentistry codes. When submitted, we use those codes to alert us that the service was not performed in a traditional office setting.

We do not currently cover D9311. In most of Aetna’s dental plans, members are allowed two problem-focused exams (i.e., D0140 or D0170) in a calendar year in addition to two comprehensive or periodic oral exams (D0150 or D0120.) More importantly, when D0140 and D0170 are performed by a specialist, those exams are not subject to frequency limits. Aetna Dental is currently invoking our disaster recovery protocols that allow us to take unique situations into account to help dental members and providers. Our “service without borders” approach allows our service team to consider a provider’s special circumstances when processing a claim.

Liberty Yes. See press release below Yes. See press release below Yes. See press release below MetLife Limited and problem focused

evaluations are typically covered by MetLife plans. To the extent it is covered by a MetLife plan, such evaluations via tele-dentistry consultation would be covered. However some employer dental plans may not cover limited and problem focused evaluations so MetLife recommends that dentists and covered

MetLife dental plans typically cover physician consultations with respect to covered services. However some employer dental plans may not cover physician consultations so MetLife recommends that dentists and covered plan members check with MetLife to determine if this service is covered under the specific employer’s dental plan that the

MetLife has developed specific criteria to address situations where an enrolled dental plan member’s dental benefits are adversely affected because the individual is a victim of the Covid-19 virus. If the claim meets these criteria and we are notified that the individual is a victim of the virus, MetLife will allow benefits. This criteria is in

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plan members check with MetLife to determine if these services are covered under the specific employer’s dental plan that the patient is enrolled in.

MetLife also recommends that dentists

and covered plan members check with MetLife to determine if tele-dentistry services which may be separate from the actual completion of the evaluations are covered under the specific employer’s dental plan that the patient is enrolled in. Benefit coverage can also be verified using MetLife’s web portal, MetDental, for dentists as well as MetLife’s interactive voice response [IVR]] capabilities.

patient is enrolled in. Benefit coverage can also be verified using MetLife’s web portal, MetDental for dentists as well as MetLife’s interactive voice response [IVR] capabilities.

place for insured dental plans. MetLife has also recommended that employers with self-funded dental plans also follow the same criteria that has been developed.

[Metlife continues to evaluate this guidance. Updates will be posted as available]

United Concordia

Yes to D0140 when performed using phone or video will be covered for the next 90 days

No There would be case-by-case exceptions. UCD expects dentists to bill 0140 for teledentistry for the next 90 days.

Humana Yes - Humana will allow benefits for tele-dentistry consultation for limited and problem-focused evaluation and re-evaluation (D0140, D0170 & D0171). Please note that the aforementioned evaluation/consultation codes should be accompanied by the tele-dentistry codes D9995 or D9996. These codes are required as descriptor codes and are not paid as an additional benefit.

Yes – Humana will allow benefits for a physician consultation (D9311) via tele-dentistry.

Frequency limits will be waived such that these evaluations do not count towards a member’s annual frequency limitations.

Principal Principal will reimburse for services when performed via tele-dentistry, same as if it is performed in a traditional dental office setting.

We do not cover code D9311 Principal has enacted our pandemic response plan, which allows us to handle claim situations on an individual basis. We will take into consideration the special

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We cover D0140 and D0170 today. We do not cover D0171. We do not offer a separate benefit for the two tele-dentistry codes

circumstances for both the member and provider when determining frequency applicability.

Guardian We approve these codes today when they are submitted, with or without Teledentistry.

No, physician consultations are not covered under our dental insurance policies

No, but we plan to reassess this policy.

Blue Cross Blue Shield

Awaiting response

Delta Dental (all companies)

Awaiting response.

United Healthcare

Awaiting response

Cigna Awaiting response GEHA Awaiting response Lincoln Life Awaiting response Starmount Awaiting response Wellpoint Awaiting response

LIBERTY ANNOUNCES EXPANDED TELEDENTISTRY TO PREVENT THE SPREAD OF CORONAVIRUS

LIBERTY Dental Plan remains fully operational and continues to monitor federal and state guidance in response to the COVID-19 Virus. LIBERTY has taken steps to ensure our members, providers, and workforce are safe and have access to vital information, as well as any assistance needed in providing or accessing emergency dental services. Our workforce is available, electronically and by telephone, to assist our members, and members may call us at any time at 888-703-6999. To better serve members who are experiencing dental pain or a potential dental emergency, LIBERTY announces the expansion of our Teledentistry Program to all members; including but not limited to, Medicaid, Medicare, Marketplace Exchanges, Employer Groups and Individual members. Our Teledentistry program allows members to use a free mobile app through the convenience of a smartphone or computer to access licensed dentists who are able to perform assessments, write prescriptions if needed, and advise on pain management strategies. In addition to making the app available and expanding the use of the program for all emergencies, LIBERTY will continue to assist members requiring further treatment by finding a local provider. Any member experiencing dental pain or a potential dental emergency should:

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• Start by contacting your dental provider for local assistance and treatment. • If your provider is unable to provide support or treatment due to closures, contact LIBERTY’s toll-free member hotline 888-703-

6999 for navigation to the Teledentistry Program. During normal and after business hours, members can access this service through our call center.

• Immediately call 911 if the situation is thought to be life-threatening. Our expanded Teledentistry Program will be available until further notice. LIBERTY will continue to monitor this fluid situation and adjust to support our members and providers as needed. For more information about LIBERTY Dental Plan and our Teledentistry Program, please contact John Carvelli at jcarvelli@libertydentalplan.com

Brought to you by the ADA’s Practice Institute, Center for Dental benefits, Coding and Quality. For questions contact dentalbenefits@ada.org

325 John Knox Rd, L103 ٠ Tallahassee, FL 32303 ٠ phone: 800.950.1150 850.205.5626 ٠ fax: 850.222.0053 ٠ www.nadl.org

Established in 1951

Updated 3/22/2020

Are Dental Laboratories Considered Essential or Non-Essential Under New Ordinances

Based on continuing developments by California, New Jersey, Florida, Illinois and New York, and soon to be more state Governors and in some case local county/city ordinances, NADL is receiving questions on how businesses are defined as it relates to essential or non-essential. In most of the state Governor executive orders executed thus far, dental offices are mentioned within the essential category, further, most orders use the wording that essential businesses includes but is not limited to hospitals, ambulatory surgery centers, dental offices….key words are includes but is not limited to; It is NADL’s belief that in most cases depending on the specific wording in your state, county or city, dental laboratories likely fall into the essential business category (that is if you make the business decision to actually stay open). This assessment is based on several arguments: 1. Dental laboratories according to the U.S. Health and Human Services Office for Civil Rights, under the Health Insurance Portability and Accountability Acts are defined as a "health care provider." 2. Under the North American Industry Classification Code, NAICS Code 339116: dental laboratories are defined as establishments that are primarily engaged in manufacturing dentures, crowns, bridges, and orthodontic appliances customized for individual application. The parent NAICS code where dental laboratories is NAICS 33911 which is listed under - Medical Equipment and Supplies Manufacturing 3. In those states where dental laboratories are required to register in order to operate, they pay registration and or license fees to either state Boards of Dentistry and/or state Departments of Health. Lastly, if dental offices are allowed to stay open even if it’s just to perform emergency or urgent care, there are specific procedures that have been listed as allowable, that would require the services of a dental laboratory to assist in completion of such work, in order for the dentist to treat the patient. This is not meant to construe a legal opinion, as each city, county, state may have different and or more specific wording in the essential business definitions. However, absent dental laboratories not being specifically named as non-essential in city, county, state orders, these factors should provide positive footing if you choose to keep your dental laboratory operational in some capacity. Below is the ADA link on emergency procedures: https://success.ada.org/~/media/CPS/Files/Open%20Files/ADA_COVID19_Dental_Emergency_DDS.pdf?utm_source=adaorg&utm_medium=covid-resources-lp&utm_content=cv-pm-emerg-def&utm_campaign=covid-19&_ga=2.116040902.1161928438.1584892218-389067976.1535481947 We continue to work to share information as it is available to support the dental laboratory community during these trying times. NADL continues to post new information primarily on its NADL Facebook Page and What's In Your Mouth Facebook Page, as those mediums facilitate faster distribution across various audiences.

D9995 and D9996 ADA Guide – Version 1 – July 17, 2017 – Page 1 of 10 ©2017 American Dental Association (ADA). All rights reserved.

D9995 and D9996 – ADA Guide to Understanding and Documenting Teledentistry Events

Developed by the ADA, this guide is published to educate dentists and others in the dental community on these procedures and their codes first published in CDT 2018 and effective January 1, 2018.

Introduction

CDT 2018 marks the first time teledentistry codes have been added to the code set. Teledentistry provides the means for a patient to receive services when the patient is in one physical location and the dentist or other oral health or general health care practitioner overseeing the delivery of those services is in another location. This mode of patient care makes use of telecommunication technologies to convey health information and facilitate the delivery of dental services without the physical constraints of a brick and mortar dental office.

The two full CDT Code entries are:

D9995 teledentistry – synchronous; real-time encounter Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.

D9996 teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.

The following pages contain a number of Questions and Answers, and Scenarios, all intended to provide readers with insight and understanding of how care is delivered and reported when teledentistry is a facet of the process.

Questions and Answers

1. What is telehealth and teledentistry?

Telehealth is not a specific service; it refers to a broad variety of technologies and tactics to deliver virtual medical, health, and education services. As an umbrella term, it is further defined when applied to specific health care disciplines, such as dentistry.

Teledentistry, according to the ADA’s Comprehensive Policy Statement on Teledentistry, refers to the use of telehealth systems and methodologies in dentistry. Teledentistry can include patient care and education delivery using, but not limited to, the following modalities:

• Live video (synchronous): Live, two-way interaction between a person (patient, caregiver, or provider) and a provider using audiovisual telecommunications technology.

• Store-and-forward (asynchronous): Transmission of recorded health information (for example, radiographs, photographs, video, digital impressions and photomicrographs of patients) through a secure electronic communications system to a practitioner, who uses the information to evaluate a patient’s condition or render a service outside of a real-time or live interaction.

• Remote patient monitoring (RPM): Personal health and medical data collection from an individual in one location via electronic communication technologies, which is transmitted

D9995 and D9996 ADA Guide – Version 1 – July 17, 2017 – Page 2 of 10 ©2017 American Dental Association (ADA). All rights reserved.

to a provider (sometimes via a data processing service) in a different location for use in care and related support of care.

• Mobile health (mHealth): Health care and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and personal digital assistants (PDA).

2. Why are there two teledentistry CDT Codes, but four delivery modalities?

Delivery of Remote Patient Monitoring (RPM) and Mobile Health (mHealth) may occur in either a synchronous or asynchronous information exchange environment.

3. What prompts the need for teledentistry?

Teledentistry is a means to an end – a patient’s oral health. The reason or reasons why a teledentistry event occurs depends on the circumstances, such as when all persons who must be involved are not able to be in the same physical location. Another determining facet is the judgment of the dentist or other oral health or general health practitioner, all acting in accordance with applicable state law, regulation or licensure.

4. How is a teledentistry event affected when the health care practitioners are in different states?

A teledentistry event is subject to applicable state law, regulation or licensure. All involved persons (the dentist or other oral health or general health care practitioner) must determine if a teledentistry event can occur when all participants are not in the same state.

5. What are the notable attributes of a synchronous encounter reported with D9995, and asynchronous teledentistry reported with D9996?

Synchronous teledentistry (D9995) is delivery of patient care and education where there is live, two-way interaction between a person or persons (e.g., patient; dental, medical or health caregiver) at one physical location, and an overseeing supervising or consulting dentist or dental provider at another location. The communication is real-time and continuous between all participants who are working together as a group. Use of audiovisual telecommunications technology means that all involved persons are able to see what is happening and talk about it in a natural manner.

Asynchronous teledentistry (D9996) is different as there is no real-time, live, continuous interaction with anyone who is not at the same physical location as the patient. Also known as store-and-forward, asynchronous teledentistry involves transmission of recorded health information (e.g., radiographs, photographs, video, digital impressions and photomicrographs of patients) through a secure electronic communications system to another practitioner for use at a later time.

6. Who would document and report a D9995 or D9996 CDT Code?

The dentist who oversees the teledentistry event, and who via diagnosis and treatment planning completes the oral evaluation, documents and reports the appropriate teledentistry CDT code. Applicable state regulations may also determine the oral health or general health practitioner who documents and reports these codes.

As noted in their descriptors, either one or the other teledentistry code is reported in addition to other procedures delivered to the patient on the date of service. In addition, both the individuals collecting records in the off-site setting and the dentist reviewing the records should document those activities in the progress notes in the patient’s chart.

D9995 and D9996 ADA Guide – Version 1 – July 17, 2017 – Page 3 of 10 ©2017 American Dental Association (ADA). All rights reserved.

7. Are there CDT Codes for: a) documenting collection and transmission of information in a teledentistry event; and b) for receipt of the information?

There are no such discrete codes. As noted in the answer to question #6, the collection, transmission and receipt actions should be noted in the patient’s record. An unspecified procedure by report code may also be used as part of this documentation, with the required narrative report containing the pertinent information.

8. Who would document and report other procedures delivered during a teledentistry event?

The dentist or other oral health or general health practitioner acting in accordance with applicable state law, regulation or licensure, reports the appropriate CDT Code for these procedures, such as prophylaxis, topical fluoride application, diagnostic images. Supervision requirements within a state practice act determine whether the dentist must document and report all the other procedures, or if they may be reported whole or in part by another type of licensed practitioner.

More than one claim submission may be necessary when:

• there is a continuum of care that begins with a teledentistry encounter at a remote location, and continues with other services being delivered at a dental practice location, or

• state practice acts permit different licensed health care practitioners to submit claims for the particular services they provided during the teledentistry encounter.

Notes:

a) Teledentistry is a mode of dental service delivery that, when applicable, is reported in addition to the other procedures provided to the patient.

b) Procedure delivery is by a natural person (e.g., dentist); the billing entity may be a natural person or a legal person (i.e., the facility where the service is delivered).

c) The ADA’s “Comprehensive Policy Statement on Teledentistry” states that dentists and allied dental personnel who deliver services through teledentistry modalities must be licensed or credentialed in accordance with the laws of the state in which the patient receives service. The delivery of services via teledentistry must comply with the state’s scope of practice laws, regulations or rules.

9. Who has responsibility for services delivered via teledentistry?

Responsibility, and liability, for services delivered is determined by applicable state law and regulations. Each dentist, hygienist and others involved in a teledentistry appointment should become familiar with applicable state or federal regulations to determine their liability exposure, and whether or not the person receiving care becomes their patient of record. Please note that “patient of record” may be defined differently under applicable state regulations. This could be a factor to consider in a teledentistry event where the patient and some members of the team of providers are in different states.

10. With responsibility comes potential liability – what should I do to protect myself and my practice when I engage in teledentistry?

As noted in the answer to question #9 (immediately above) liability is determined by applicable state law and regulations. This concern should be discussed with your personal legal counsel and insurance advisor to determine whether or not your existing liability insurance policies cover

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this risk. Additional personal, professional and practice insurance coverage may be needed to address any coverage gaps.

11. How would D9995 or D9996 be reported on a dental claim submission?

A claim submission includes the services provided to one patient. Each claim detail line identifies the particular procedure and the date it was delivered to the patient. D9995 or D9996 are reported in addition to the codes for other procedures (e.g., prophylaxis; diagnostic imaging) reported separately when the patient presents for care.

Appendix 1 contains special claim completion instructions for the ADA Dental Claim Form (©2012). These instructions are envisioned as the model for reporting teledentistry CDT Codes on the HIPAA standard electronic dental claim transaction (837Dv5010).

12. Are D9995 and D9996 used when a claim for teledentistry is submitted to a medical benefit plan?

D9995 and D9996 are CDT Codes that are applicable to claims filed against a dental benefit plan. Dental claim content, format and completion instructions differ from claims filed against a medical benefit plan. Claims filed against a medical benefit plan use a unique format, are prepared with different code sets, and follow their own completion instructions. Medical benefit claims are outside the scope of this guide.

13. What documentation should I maintain in my patient records, and what will be needed on a claim submission when reporting D9995 and D9996?

The patient record must include the CDT Code that reflects the type of teledentistry encounter, and there may be additional state documentation requirements to satisfy. A claim submission must include all required information as described in the completion instructions for the ADA paper claim form and the HIPAA standard electronic dental claim. Some government programs (e.g., Medicaid) may have additional claim reporting requirements.

14. What dental benefit plan coverage – commercial or governmental – is anticipated?

Current dental benefit plan coverage and reimbursement provisions should apply to services delivered in-office and via teledentistry. However, there is no expectation that commercial and government dental benefit plans must create new coverage provisions pertaining to teledentistry. Further, coverage and reimbursement for D9995 and D9996 is likely to vary between commercial benefit plan offerings and by state for government programs (e.g. Medicaid).

The ADA’s “Comprehensive Policy Statement on Teledentistry” sets an expectation of consistent and equitable coverage for all procedures associated with teledentistry services – as noted in the following extract.

Reimbursement: Dental benefit plans and all other third-party payers, in both public (e.g. Medicaid) and private programs, shall provide coverage for services using teledentistry technologies and methods (synchronous or asynchronous) delivered to a covered person to the same extent that the services would be covered if they were provided through in-person encounters. Coverage for services delivered via teledentistry modalities will be at the same levels as those provided for services provided through in-person encounters and not be limited or restricted based on the technology used or the location of either the patient or the provider as long as the health care provider is licensed in the state where the patient receives service.

D9995 and D9996 ADA Guide – Version 1 – July 17, 2017 – Page 5 of 10 ©2017 American Dental Association (ADA). All rights reserved.

This policy statement concerns equitable application of existing coverage and reimbursement provisions, and recognizes that dental benefit plan coverage and reimbursement provisions are likely to vary.

15. How would dental benefit plan reimbursements, meaning claim payments, be processed when more than one oral health or medical health practitioner is involved in a teledentistry encounter?

Dental benefit plan reimbursements are, as today, payable to the billing entity on the claim submission, who may be a natural person (e.g., dentist) or a legal person (e.g., dental practice). Allocation of reimbursements is subject to the business relationships between the reimbursement’s recipient and other oral health or medical health practitioners involved in the teledentistry event – such relationships are outside the scope of this guide.

D9995 and D9996 ADA Guide – Version 1 – July 17, 2017 – Page 6 of 10 ©2017 American Dental Association (ADA). All rights reserved.

Coding Scenarios

Note: These two scenarios assume that the persons and services involved are in accordance with local state practice act, laws, rules, and regulations

1. Assessments at Senior Living Facility – A “Real-Time” Teledentistry Encounter

A hygienist is scheduled to meet with residents of a local senior living facility in order to assess their potential need for dental treatment. The facility does not have dedicated space or equipment for dental assessments, so the hygienist brings a laptop computer and an intraoral camera. This equipment is used to enable information capture and a real-time connection with the dentists via a HIPAA-compliant (Security and Privacy) connection that uses encryption and a secure “cloud” server.

During her or his visit the hygienist records patient information that includes perio probing and charting, a visual oral cancer examination, and capture of high-quality intraoral diagnostic images. The dentist through this real-time connection sees 10 patients exhibiting evidence of the need for immediate or further care (e.g., restorations; soft tissue biopsies). Several of the senior living facility residents schedule their care at the affiliated brick and mortar dental practice.

What CDT Codes would be used to document the services provided on the day of this real-time encounter?

In this scenario patients present for diagnostic and evaluative procedures. The dentist is at a different physical location with complete and immediate access to patient information being captured, and the ability to interact vocally and visually with the patient

The following procedure codes are reported by the oral health or general health practitioner, as applicable, for each patient who received the services described.

D0191 assessment of a patient

D0350 2D oral/facial photographic image obtained intra-orally or extra-orally

D0351 3D photographic image

Note: The types of diagnostic image (2-D or 3-D), as well as the number of separate images captured would be determined by the dentist to adequately document the clinical condition.

D01xx (oral evaluation CDT Code – determined and reported by the dentist – or by another oral health or general health practitioner in accordance with applicable state law)

D9995 teledentistry – synchronous; real-time encounter

Note: D9995 is reported once for each patient, in the same manner as CDT Code “D9410 house/extended care facility call” (once per date of service per patient) to document the type of teledentistry interaction in this setting on the date of service.

D9995 and D9996 ADA Guide – Version 1 – July 17, 2017 – Page 7 of 10 ©2017 American Dental Association (ADA). All rights reserved.

2. Screening Services at an Off-Site Setting - A “Store and Forward” Teledentistry Encounter

A hygienist in an off-site setting collects a full set of electronic dental records as allowed in the state where the facility is located. These records include radiographs, photographs, charting of dental conditions, health history, consent, and applicable progress notes. This stored information is forwarded to the dentist via a HIPAA-compliant (Security and Privacy) connection that uses encryption and a secure “cloud” server. At a later time the dentist completes a comprehensive oral examination, diagnosis, and treatment plan.

What CDT Codes would be used to document the services provided in this scenario?

In this scenario the individual interacts only with the hygienist. Information collected is conveyed to the dentist for diagnosis, evaluation and treatment planning at a later time, and possibly at a different location. This dentist has no live vocal or visual interaction with the individual or hygienist during information collection.

The following procedure codes are reported, as applicable, for each individual who received the services described above.

D0190 screening of a patient

D0350 2D oral/facial photographic image obtained intra-orally or extra-orally

D0351 3D photographic image

Note: The types of diagnostic image (2-D or 3-D), as well as the number of separate images captured would be determined by the clinical condition being documented.

D9996 teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review

Note: D9996 is reported once for each individual to document the type of teledentistry interaction in this setting on the date of service.

D9995 and D9996 ADA Guide – Version 1 – July 17, 2017 – Page 8 of 10 ©2017 American Dental Association (ADA). All rights reserved.

Appendix 1

Special Claim Completion Instructions – Coding a Teledentistry Event

A teledentistry event claim or encounter submission involves reporting the appropriate Place of Service (POS) code and CDT Code.

• POS code 02 (Telehealth – the location where health services and health related services are provided or received, through telecommunication technology) was added to that code set effective January 1, 2017.

• CDT Codes D9995 and D9996 are effective January 1, 2018. These codes are reported in addition to other services (e.g., diagnostic) reported separately when the patient presents for care. They document services provided by the dentist, or other practitioner providing care, who is not in direct contact with the patient at the time of the encounter.

These instructions apply only to the ADA Dental Claim Form. Please contact your practice management system vendor for guidance when reporting D9995 or D9996 on the HIPAA standard electronic dental claim (837D v 5010).

POS code 02 is recorded in Item # 38 on the claim form.

Note: POS is at the Claim level for dental services, which means it pertains to all services reported on the claim submission.

D9995 or D9996 is recorded on any unused line (1 through 10) in the ‘Record of Services Provided' section of the form.

The following special instructions for Items 24 - 31 apply to the service line on which D9995 or D9996 is reported.

24. Procedure Date (MM/DD/CCYY): Enter date the dental procedures delivered in the teledentistry encounter were performed. The date must have two digits for the month, two for the day, and four for the year.

25. Area of Oral Cavity: Not Used

D9995 and D9996 ADA Guide – Version 1 – July 17, 2017 – Page 9 of 10 ©2017 American Dental Association (ADA). All rights reserved.

26. Tooth System: Not Used

27. Tooth Number(s) or Letter(s): Not Used

28. Tooth Surface: Not Used

29. Procedure Code: Enter D9995 or D9996 as applicable. Only one type of teledentistry service may be reported for the encounter.

29a Diagnosis Code Pointer: Not Used

29b Quantity: Cannot be greater than “1”

30. Description: Enter “Teledentistry – Synchronous” or “Teledentistry – Asynchronous” as applicable.

31. Fee: Enter the full fee for the reported teledentistry procedure that is related to the other procedures delivered in the encounter.

Note: A full fee may be zero dollars.

In addition to the above, Item # 56 in the claim’s “Treating Dentist and Treatment Location” block is the location where the patient being treated is physically located, and may differ from the where the “treating dentist” is located.

56. Address, City, State, Zip Code: Enter the physical location where the treatment was rendered. Must be a street address, not a Post Office Box.

D9995 and D9996 ADA Guide – Version 1 – July 17, 2017 – Page 10 of 10 ©2017 American Dental Association (ADA). All rights reserved.

Questions or Assistance?

Call 800-621-8099 or send an email to dentalcode@ada.org

Notes:

• This document includes content from the ADA publication – Current Dental Terminology (CDT) ©2017 American Dental Association (ADA). All rights reserved.

• This document includes content from the ADA publication – ADA Dental Claim Form ©2012 American Dental Association (ADA). All rights reserved.

• Version History

Date Version Remarks – Change Summary

07/17/2017 1 Initial publication

325 John Knox Rd, L103 ٠ Tallahassee, FL 32303 ٠ phone: 800.950.1150 850.205.5626 ٠ fax: 850.222.0053 ٠ www.nadl.org

Established in 1951

Update date 3/25/2020

NADL COVID-19 Resources

The National Association of Dental Laboratories is keenly aware of the business challenges and confusion that our members are facing relative to the COVID-19 pandemic. NADL has created an ever-growing list of focused resource links to help members with questions on a variety of issues. NADL is working as carefully as possible to only post resource links from validated sources. NADL continues to post new information primarily on its NADL Facebook Page and What's In Your Mouth Facebook Page, as those mediums facilitate faster distribution across various audiences. If you have not liked these pages or are not a follower of these Facebook pages, please do so, as NADL can post the most up-to-date information more frequently on those communication mediums. NADL has been posting updates on Facebook sometimes 4-5 times a day. NADL's Board of Directors has discussed the COVID-19 pandemic on a recent conference call, and NADL staff is in frequent communication with the NADL Executive Committee Officers within the Board. NADL staff is in communication daily with the American Dental Association and is also in communication with various federal government agencies. NADL as an association, recognizes that dental laboratory owners, managers, and technicians are extremely concerned with what has already occurred in our profession as a result of the COVID-19 pandemic. These concerns are primarily focused on infection control (for work that may be coming in, although cases are certainly declining daily) based on Executive Orders of State Governors or State Boards of Dentistry. The other primary areas of focus are on the impact of lack of work on operating revenue for the business and resulting paths that owners are facing relative to short and long term human resource decisions on layoffs, furloughs, reductions in pay, and reduction in working hours. More and more state governors are passing executive orders for hospitals, ambulatory surgery centers, and dental offices on restrictions of care. These actions are twofold: 1) to mitigate what is expected to be a shortage in the supply chains of personal protective equipment and 2) to facilitate social distancing. The executive orders also vary in length with some states extending these requirements into June 2020. These orders and the duration of these orders can be reduced or extended based on conditions in a specific state. To help dental laboratories understand how most states are addressing dental office requirement, the following list illustrates what dentists are allowed to perform. Again, each state may modify this general list based on conditions, and the number of cases in their state. For the most up-to-date information on dental office requirements in a specific state, visit the website of the State Board of Dentistry or state dental association in your state.

325 John Knox Rd, L103 ٠ Tallahassee, FL 32303 ٠ phone: 800.950.1150 850.205.5626 ٠ fax: 850.222.0053 ٠ www.nadl.org

Established in 1951

The following is a statement from the American Dental Association.

Dental emergencies, according to the ADA, “are potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to] alleviate severe pain or infection.” Conditions include uncontrolled bleeding; cellulitis or a diffuse soft tissue bacterial infection with intraoral or extraoral swelling that potentially compromises the patient’s airway; or trauma involving facial bones that potentially compromises the patient’s airway. “The guidance may change as the COVID-19 pandemic progresses,” according to the Association. “Dentists should use their professional judgment in determining a patient’s need for urgent or emergency care.” As part of the emergency guidance, the Association added urgent dental care which “focuses on the management of conditions that require immediate attention to relieve sever pain and/or risk of infection and to alleviate the burden on hospital emergency departments.” Examples of urgent dental care treatments, which should be treated as minimally invasively as possible, include: • Severe dental pain from pulpal inflammation. • Pericoronitis or third-molar pain. • Surgical postoperative osteitis or dry socket dressing changes. • Abscess or localized bacterial infection resulting in localized pain and swelling. • Tooth fracture resulting in pain or causing soft tissue trauma. • Dental trauma with avulsion/luxation. • Dental treatment cementation if the temporary restoration is lost, broken or causing gingival irritation. Other emergency dental care includes extensive caries or defective restorations causing pain; suture removal; denture adjustments on radiation/oncology patients; denture adjustments or repairs when function impeded; replacing temporary filling on endo access openings in patients experiencing pain; and snipping or adjustments of an orthodontic wire or appliances piercing or ulcerating the oral mucosa. “The American Dental Association recognizes the unprecedented and extraordinary circumstances dentists and all health care professionals face related to growing concern about COVID-19,” according to the March 16 statement from ADA President Chad P. Gehani. “Concentrating on emergency dental care will allow us to care for our emergency patients and alleviate the burden that dental emergencies would place on hospital emergency departments.” Nonemergency dental procedures, according to the Association, include but are not limited to: • Initial or periodic oral examinations and recall visits, including routine radiographs. • Routine dental cleaning and other preventive therapies. • Orthodontic procedures other than those to address acute issues (e.g., pain, infection, trauma). • Extraction of asymptomatic teeth. • Restorative dentistry including treatment of asymptomatic carious lesions. • Aesthetic dental procedures.

325 John Knox Rd, L103 ٠ Tallahassee, FL 32303 ٠ phone: 800.950.1150 850.205.5626 ٠ fax: 850.222.0053 ٠ www.nadl.org

Established in 1951

NADL is submitting a letter to the U.S. Department of Labor advocating for clarity on how businesses, including dental laboratories under 50 employees, can demonstrate that meeting current federal laws on "paid leave" and "FMLA" can result in actual closure/shutting of the doors of some businesses. NADL staff is on the phone in some cases over ten hours a day, working with individual dental laboratories to help direct them to appropriate outside legal, human resource, and tax service providers that can assist them in their specific situation. Each scenario is different given the size of the dental laboratory, demographics of that laboratory's workforce, and geographic location (based on local or state guidance or mandates). NADL is working diligently to assist as many people as it can in a quickly changing economic and regulatory environment. Please continue to visit NADL's news page on http://www.nadl.org and its social media platforms for the most up to date information. These resources are categorized by subject matter.

General Business Links

https://www.dol.gov/newsroom/releases/whd/whd20200324 https://www.insperity.com/blog/covid-19-pandemic/ From NADL’s Business Services Affinity Partner https://www.insperity.com/blog/3-steps-dealing-workplace-tension-caused-current-events/ From NADL’s Business Services Affinity Partner https://www.insperity.com/blog/motivating-employees-in-uncertain-times/ From NADL’s Business Services Affinity Partner https://www.covid19.polsinelli.com/blog/congress-gets-in-the-act-families-first-coronavirus-response-act From NADL’s Outside Law Firm https://www.covid19.polsinelli.com/blog/manufacturers-distributors-and-retailers-covid-19-forces-you-to-consider-your-contractual-remedies From NADL’s Outside Law Firm https://www.covid19.polsinelli.com/ From NADL’s Outside Law Firm

State by State Summary of Board of Dentistry Actions on

Practice Closures and Procedures

http://www.nnoha.org/download/covid-19-coronavirus-resources/

325 John Knox Rd, L103 ٠ Tallahassee, FL 32303 ٠ phone: 800.950.1150 850.205.5626 ٠ fax: 850.222.0053 ٠ www.nadl.org

Established in 1951

American Dental Association Guidance on COVID-19 https://success.ada.org/en/practice-management/patients/~/link.aspx?_id=6C881EF4A7884989A80BA475F9A116ED&_z=z https://success.ada.org/en/practice-management/patients/coronavirus-frequently-asked-questions

Business Links Related to Wage and Hour; Disaster Relief Programs

https://disasterloan.sba.gov/ela/Declarations/Index - The U.S. Small Business Administration is offering designated states and territories low-interest federal disaster loans for working capital to small businesses suffering substantial economic injury as a result of the Coronavirus (COVID-19). Upon a request received from a state’s or territory’s Governor, SBA will issue under its own authority, as provided by the Coronavirus Preparedness and Response Supplemental Appropriations Act that was recently signed by the President, an Economic Injury Disaster Loan declaration. https://www.sba.gov/about-sba/sba-newsroom/press-releases-media-advisories/sba-provide-disaster-assistance-loans-small-businesses-impacted-coronavirus-covid-19 https://www.sba.gov/local-assistance/find/?type=SBA%20Regional%20Office&pageNumber=1 Contact List of Regional SBA Offices https://www.sba.gov/local-assistance/find/?type=SBA%20District%20Office&pageNumber=1 Contact List of District SBA Offices https://www.irs.gov/newsroom/treasury-irs-and-labor-announce-plan-to-implement-coronavirus-related-paid-leave-for-workers-and-tax-credits-for-small-and-midsize-businesses-to-swiftly-recover-the-cost-of-providing-coronavirus Some states may offer state business loan assistance outside of the SBA national program. To determine if your state has such resources, look for local programs at: https://eda.gov/resources/ http://www.economicdevelopmenthq.com/economic-development-agencies/united-states/ https://www.ready.gov/business-impact-analysis https://www.ready.gov/pandemic https://www.dol.gov/agencies/whd/fact-sheets/70-flsa-furloughs Wage and Hour Guidance

https://nadl.org?gabnbk Employee Pay and the Coronavirus From NADL’s Outside HR Firm

325 John Knox Rd, L103 ٠ Tallahassee, FL 32303 ٠ phone: 800.950.1150 850.205.5626 ٠ fax: 850.222.0053 ٠ www.nadl.org

Established in 1951

Business Guidance on COVID-19 from OSHA and CDC

(including infection control) https://www.cdc.gov/coronavirus/2019-ncov/about/index.html https://www.osha.gov/Publications/OSHA3990.pdf https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fspecific-groups%2Fguidance-business-response.html https://dentallabs.org/managing-the-coronavirus-in-a-dental-lab-or-dental-practice-setting/ https://info.safelinkconsulting.com/blog/coronavirus-dental-laboratory

From NADL’s OSHA/FDA Partner SafeLink Consulting Inc.

State and Local COVID-19 Response Information

https://docs.google.com/spreadsheets/d/e/2PACX-1vRlJWZJ7OkGUW57_rdA2n3xBJ3qjW6u4Z9N6K9Y5L4bM_6H7-S308qdKmJfpVstYWf300nyujvZPFSy/pubhtml?urp=gmail_link Footnote: Many NADL members have had questions on “non-essential vs. essential businesses”. To NADL’s knowledge there is no federal guidance, definition or checklist that has been established to define how dental laboratories are classified. These classifications are being left to states or local (counties and cities) to make those determinations. NADL members should sign up for alerts from their state and local government entities to get the most real time local information on this subject. Many NADL members have had questions on ADA’s role with dental practices. ADA is a nonprofit organization just like NADL. ADA is a not a government agency, it has no authority to mandate its members to do anything as it relates to guidance. It can only provide recommendations. Only government entities, at the federal, state or local level, including State Boards of Dentistry can put forth mandates that direct dental offices relative to full or partial closure, providing only urgent or emergency care, etc. Dental laboratories are faced with making tough decisions relative to business continuity, considering layoffs, furloughs, reduction in pay for employees. Each situation is case specific and dental laboratory owners/managers should consult with outside Human Resource professionals if you do not have an inside/in house Human Resource department or personnel. These types of significant decisions should be measured for both short and long term implications. NADL will continue to update this document with additional resources as we are able to. Have an additional resource that would be helpful to include or have additional questions? Please contact NADL by phone at (800) 950-1150 or by email at nadl@nadl.org.

SAMPLE ESSENTIAL EMPLOYEE TEMPLATE FOR CRITICAL BUSINESS

[Company Letterhead]

March 23, 2020

Subject: EMPLOYEE OF AN ESSENTIAL BUSINESS

To Whom It May Concern:

<INSERT EMPLOYEE NAME> is considered an essential employee under the <Add

Applicable State or Local Government (i.e., CA)> Stay at Home Order issued in

<March of 2020>, and similar local orders, and will be reporting to work for our

company, which is considered an Essential Business under <federal essential critical

infrastructure guidelines and state and local orders> due to the fact that we

manufacture devices essential to support urgent and emergency dentistry.

<INSERT EMPLOYEE NAME> will be coming into the office each day as necessary

<INSERT HOURS AND DAYS OR DATES>. Please allow this employee entry into our

offices at <INSERT OFFICE ADDRESS>. <INSERT EMPLOYEE NAME> will produce

a valid driver’s license as a proof of identification.

This letter is valid until <DATE>. To validate this employee as an essential employee,

please contact <INSERT NAME AND PHONE NUMBER>.

The safety of our employees, our customers, and the communities in which we operate

are our top priorities. <INSERT COMPANY NAME> is following CDC, state, and local

guidance and is taking necessary steps in its operations to reduce the likelihood of spread

of COVID-19. In addition, we continue to closely monitor the latest COVID-19 updates

and are taking all appropriate actions.

Thank you for your cooperation.

Sincerely,

<INSERT NAME AND TITLE>

COVID-19PandemicEmergencyDentalTreatmentConsentForm

I, _____________________________________, knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. Dental procedures create water spray which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

• I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of the dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office. ___________ (Initial)

• I have been made aware of the CDC, ODA, and ADA guidelines that under the current pandemic all non-urgent dental care is not recommended. Dental visits should be limited to the treatment of pain, infection, conditions that significantly inhabit normal operation of teeth and mouth, and issues that may cause anything listed above within the next 3-6 months. ___________ (Initial)

• I confirm that I am seeking treatment for a condition that meets these criteria. ___________ (Initial)

I confirm that I am not presenting any of the following symptoms of COVID-19 listed below: ___________ (Initial)

• Fever • Shortness of breath • Dry cough • Runny nose • Sore throat

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. In addition, the CDC recommends social distancing of at least 6-feet for a period of 14 days to anyone who has, and this is not possible with dentistry. ___________ (Initial)

I verify that I have not traveled outside the United States in the past 14-days to countries that have been affected by COVID-19. ___________ (Initial)

I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14-days. ___________ (Initial)

Patient/Guardian

Signature: _____________________________________ Date: _____________________________

DentalPatientConsentForm

The patient, ____________________________, will hold harmless and indemnify, the doctor, practice, associates, employees, successors, assigns, legal representatives, organizers, sponsors, and supervisors, against any claims, and actions, in exchange for dental treatment during the events of COVID-19 National Emergency from the period of time _________________ to ________________. “You are receiving dental care during the events of a COVID-19 National Emergency. Please be advised that there may be risks in being in the proximity of dentists, patients and staff. We are taking precautions to limit the spread of disease, yet there is still a possibility of transmission.”

Acknowledgement I, ________________________, make this decision of my own free will relying upon my knowledge and judgment of any injury I may have sustained or possible transmission of COVID-19 during treatment and my decision to release has not been affected by any false statements or representations pertaining to those injuries. I understand that this action is just a business decision and agree this represents a compromise between the patient and the doctor. Accordingly, this agreement is not an admission of any liability regarding the doctor, practice, associates, employees, successors, assigns, legal representatives, organizers, sponsors, and supervisors, against any claims, and actions. I have carefully read this release and understand its contents, and I am signing it of my own free act. Patient/Guardian

Signature: _____________________________________ Date: _____________________________

Treating Dentist

Signature: _____________________________________ Date: ______________________________

EmployeeConsentForm

The employee, ____________________________, will hold harmless and indemnify, the doctor, practice, associates, other employees, successors, assigns, legal representatives, organizers, sponsors, and supervisors, against any claims, and actions, in exchange for working to deliver dental care during the events of COVID-19 National Emergency from the period of time _________________ to ________________.

You are delivering dental care during the events of a COVID-19 National Emergency. Please be advised that there may be risks in being in the proximity of dentists, patients and other staff. We are taking precautions to limit the spread of disease, yet there is still a possibility of transmission.

Acknowledgement

I, ________________________, make this decision of my own free will relying upon my knowledge and judgment of any injury I may have sustained or possible transmission of COVID-19 while delivering dental care to patients and my decision to release has not been affected by any false statements or representations pertaining to those injuries. I understand that this action is just a business decision and agree this represents a compromise between the employee and the doctor. Accordingly, this agreement is not an admission of any liability regarding the doctor, practice, associates, employees, successors, assigns, legal representatives, organizers, sponsors, and supervisors, against any claims, and actions. I have carefully read this release and understand its contents, and I am signing it of my own free act.

Employee

Signature: _____________________________________ Date: _____________________________

Witness

Signature: _____________________________________ Date: ______________________________