Patient Consent Form: For Collection, Use And Disclosure Of Personal Information
The privacy of your personal information is an essential part of our dental office. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will also be as open and transparent as possible about the way we handle your personal information.
At Thamesford Family Dental, Dr. Scott Fairbairn acts as the Privacy Information Officer.
All staff members, in contact with your personal information, are aware of its sensitive nature and are trained in the appropriate uses and protection of it.
Attached to this consent form, we have outlined what our office is doing to ensure that:
1) Only information needed to provide dental care is collected.
2) Information will be shared only with your consent.
3) Legislation and privacy protection protocols will be complied with regarding storage, retention and destruction of information.
4) Our privacy protocols comply with privacy legislation and the Royal College of Dental Surgeons of Ontario regulations.
If you have any questions, please ask either Dr. Fairbairn or a staff member.
How Thamesford Family Dental Collects, Uses and Discloses Patients' Personal Information
We 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 dental needs and provide dental care
* To advise you of treatment options
* To enable us to contact you
* To establish and maintain communication with you to contact you to book and confirm appointments.
* To communicate with other treating health-care providers, including specialists, medical doctors and general dentists and others involved in your immediate medical and dental care.
* 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 parties and payment
* To comply with legal and regulatory requirements, including the delivery of patients' charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
* To comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and review of patient's 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 prospective 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 material for the Health Professions Appeal and Review Board (HPARB)
* To invoice for goods and services, process credit card payments, and collect unpaid accounts.
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 disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and disclosure of your personal information, we will seek your approval in advance.
Regulatory authorities may access your information under the terms of the Regulated Health Professions Act (RHPA) for the Royal College of Dental Surgeons of Ontario to fulfill its mandate under the RHPA and for the defence of a legal issue.
Our office will not under any conditions supply your insurer with your confidential medical history, or in the case of any party requesting such information, release it without obtaining your approval to do so. Additionally, you may withdraw your consent for use or disclosure of your personal information, and we will explain the implications of that decision.
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 data.
I know that your office has a Privacy Code, and I can ask to see the Code at any time.
I agree that Dr. Scott Fairbairn of Thamesford Family Dental can collect, use and disclose personal information about me as set out above in the information about the office's privacy policies.