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:
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:
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.
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
Signature of witness:
© 2023 Amanda Bolle DD, RDH