PATIENT CONSENT FORM: FOR COLLECTION, USE, AND DISCLOSURE OF PERSONAL INFORMATION
Privacy of your personal information is an important part of our office providing 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 our office, Amanda Bolle DD is 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 College of Denturists of Ontario (CDO), and the law.
Do not hesitate to discuss our policies with me 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 OUR OFFICE COLLECTS, USES,
AND DISCLOSES PATIENTS’ PERSONAL 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 the office is using and disclosing your information.
Our office will collect, use and disclose information about you
for the following purposes:
- to deliver safe and efficient patient care
- to identify and to ensure continuous high-quality service
- to assess your health needs and provide health care
- to advise you of treatment options
- to enable us to contact you
- to establish and maintain communication with you
- to offer and provide treatment, care, and services in relation to the oral maxillofacial complex and dental care generally
- to communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists
- to allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments
- to allow us to efficiently follow-up for treatment, care, and billing
- for teaching and demonstrating 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 the delivery of patients’ charts and recordsto the CDO in
a timely fashion, when required, according to the provisions
of the Regulated Health Professions Act (RHPA)
- to comply with agreements/undertakings entered into voluntarily by the member with the CDO, including the delivery and/or review of patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes
- to permit potential purchasers, practice brokers, or advisors to evaluate the dental practice
to allow potential purchasers, practice brokers, or advisors to conduct an audit in preparation for a practice sale - to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any
- to prepare materials for the Health Professions Appeal and Review Board
- to invoice for goods and services
- to process credit card payments
to collect unpaid accounts - to assist this office
- to comply with all regulatory requirements
- to comply generally with the law
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. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Your information may be accessed by the regulatory authorities under the terms of the RHPA for the purposes of the CDO fulfilling its mandate under the RHPA, and for the defense of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly to you for review, and your specific consent. 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. You may withdraw your consent for the use or disclosure of your personal information, and we will explain the ramifications of that decision and the process.
PATIENT CONSENT
I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information. I know that your office has a Privacy Code, and I can ask to see the code at any time.
I agree that Amanda Bolle Denture Services can collect, use and disclose personal information about as set out above in the information about the office’s privacy policies.
Signature of patient/guardian/POA
Print name of patient/guardian/POA
Date:
Signature of witness: