Healthcare Itero Agreement

HEALTHCARE ITERO AGREEMENT

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History

Procedure Description and Consent for iTero Digital Scanning

The provider will perform a non-invasive intraoral digital scan using an iTero digital scanning system. The scan captures digital images and three-dimensional digital models of the dentition and surrounding oral tissues for diagnosis, treatment planning, fabrication of appliances, and clinical recordkeeping. The scan does not involve ionizing radiation.

I understand the purpose of the scan, the nature of the procedure, and the expected benefits, including improved diagnostic accuracy and digital workflow for appliance fabrication. Reasonable alternatives to digital scanning, when applicable, include traditional physical impressions or foregoing imaging.

I acknowledge the following material risks and limitations: transient gagging or discomfort, limitations of digital capture leading to repeat scans if necessary, potential for data transmission errors, and the possibility that scanned data may not reproduce soft tissue details required for some appliances. No guarantee has been made regarding the outcome of any treatment based upon scanned data.

Data Use, Storage, and Disclosure

By signing this Agreement I authorize the collection, creation, storage, and use of digital scans and associated health information for my care. The provider may store scanned data on secure local systems and on secure cloud services operated by approved vendors for the purposes set forth in this Agreement.

I authorize disclosure of scanned data to dental laboratories, treatment planning services, referral providers, and insurance payors as necessary for appliance fabrication, treatment coordination, or claims processing. I understand that disclosures to third-party vendors are made under business associate agreements or similar contractual protections where applicable.

I understand that my identifiable health information will not be used for research, education, or marketing without separate written authorization, except that de-identified or aggregated data may be used for legitimate clinical, educational, or quality improvement purposes.

Authorizations and Acknowledgements

Please indicate your choices below by checking each box to provide specific consent where required:

I consent to intraoral digital scanning with the iTero system for diagnostic and treatment purposes.

I consent to storage of my scanned data for clinical recordkeeping and future clinical use by the provider.

I consent to disclosure of scanned data to dental laboratories and manufacturers for appliance fabrication.

I authorize disclosure of scanned data to insurance companies for claims adjudication as necessary.

I consent to use of de-identified scan data for educational, clinical quality improvement, or research purposes.

Privacy Notice Acknowledgment

I acknowledge that I have been offered or provided with a copy of the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights with respect to that information. Acknowledged

Retention, Revocation, and Liability

Scanned data will be retained in accordance with the provider's record retention policy and applicable law. I understand that I may revoke this authorization at any time by delivering written notice to the provider, except to the extent that the provider has already acted in reliance on the authorization. Revocation will not affect disclosures made prior to receipt of revocation.

The provider and associated vendors will take reasonable steps to protect the confidentiality and security of my scanned data. To the extent permitted by law, I release the provider from liability for inadvertent disclosures that may occur despite reasonable safeguards.

Fees and Financial Responsibility

There is no additional fee for performing an iTero digital scan when provided as part of standard clinical services unless otherwise disclosed. I understand I remain responsible for any fees associated with appliances, laboratory services, or treatments created from scanned data that are not covered by my insurer.

Authorization Period

This authorization is effective on the date signed below and will remain in effect until: unless earlier revoked in writing.

Certification

I certify that I have read and fully understand this Healthcare iTero Agreement. I have had the opportunity to ask questions and have received satisfactory answers. My signature below indicates that I give informed consent for the digital scanning procedure and for the uses and disclosures of my scanned data as described above.

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