PATIENT CONSENT FORM: FOR COLLECTION, USE AND
DISCLOSURE OF PERSONAL INFORMATION
Privacy of your personal information is an important part of our office in order to provide you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients.
In this office, the office manager acts as the Privacy Information Officer.
All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.
Attached to this consent form, we have outlined what our office is doing to ensure that:
- Only necessary information is collected about you.
- We only share your information with your consent.
- Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols.
- Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law.
Do not hesitate to discuss our policies with the office manager or any member of our office staff. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care.
How We Use and Disclose Your Information
Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information.
This office will collect, use and disclose information about you for the following purposes:
- To deliver safe and efficient patient care.
- To identify and ensure continuous high-quality service.
- To assess your health needs and provide health care.
- To communicate with immediate family members as required.
- To advise you of treatment options.
- To enable us to establish and maintain communication with you.
- To offer and provide treatment, care, and services related to the oral and maxillofacial complex and dental care generally.
- To communicate with other treating health-care providers, including specialists and referring dentists.
- To maintain communication and contact with you, distribute health-care information, and book and confirm appointments.
- To efficiently follow up regarding treatment, care, and billing.
- For teaching and demonstration purposes on an anonymous basis.
- To complete and submit dental claims for third-party adjudication and payment.
- To comply with legal and regulatory requirements, including delivery of patient charts and records to the Royal College of Dental Surgeons of Ontario when required.
- To comply with agreements and undertakings entered into voluntarily with the Royal College of Dental Surgeons of Ontario.
- To permit potential purchasers, practice brokers, or advisors to evaluate the dental practice and conduct audits in preparation for a potential practice sale.
- To deliver your charts and records to the dentist's insurance carrier for liability assessment and damage quantification, if applicable.
- To prepare materials for the Health Professions Appeal and Review Board (HPARB).
- To invoice for goods and services.
- To process credit card payments.
- To collect unpaid accounts.
- To assist this office in complying with all regulatory requirements.
- To comply generally with the law.
Consent for Collection, Use, and Disclosure
By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use, and/or disclosure of your personal information for the purposes listed above. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.
Access by Regulatory Authorities
Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defence of a legal issue.
Insurance Requests
Our office will not under any conditions supply your insurer with your confidential medical history. In the event that such a request is made, we will forward the information directly to you for review and for your specific consent.
Unusual Information Requests
When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate.
Withdrawal of Consent
You may withdraw your consent for the use or disclosure of your personal information. We will explain the ramifications of that decision and the process involved.
