Patient Privacy Consent Form

642 Upper James Street, Hamilton, Ontario. L9C 2Z2

Phone: +1-905-574-9617 Fax: +1-905-574-9691

Email: info@thedentalplace.co Website: www.thedentalplace.co

Privacy of your personal information is an essential part of our office providing you with quality 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 Privacy Information Office is:

Dr. Prathana Davla

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.

In this 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 & destruction of your personal information comply with existing legislation & privacy protocols.
Our privacy protocols comply with privacy legislation, the standards of our regulatory body and the law.

Do not hesitate to discuss our policies with me or any member of our office staff.

Please ensure that every staff person in our office is committed to ensuring that you receive the best quality care.

Signature*

HOW OUR OFFICE USES THE COLLECTED PERSONAL INFORMATION:

Our office understands the importance of protecting your personal information. Below, we have outlined how our office uses the personal information you have shared with us:

To deliver safe and efficient patient care.
To identify and ensure continuous, high-quality service.
To assess your health and oral hygiene needs.
To advise you on treatment options.
This will enable us to contact and maintain continuous communication with you for various official and other reasons as it may be required from time to time.
Communicate with other treating healthcare providers, including specialists and referring doctors.
This allows us to efficiently follow up on treatment, care, and billing.
For teaching and demonstrating purpose on an anonymous basis.
To share our latest offerings and send in appointment reminders.
To comply with legal and regulatory requirements, including delivering patient charts & records to governing bodies in a timely fashion, when required, according to the provisions of the Regulated Health Professional Act.
To comply with agreements/undertakings entered into voluntarily by the member with governing bodies, including the delivery &/or review of patient charts and records in a timely fashion for regulatory & monitoring purposes.
To permit/allow potential purchasers, practice brokers, and advisors to audit and evaluate the office for sale or other purposes like raising additional funds, etc.
To deliver your charts and records to the office’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 (HPARB).
To invoice for goods and services.
To process credit and debit card payments.
To collect unpaid accounts receivable.
To assist this office in complying with regulatory and legal requirements.
To comply generally with the Law.

Patient or Parent/Guardian Signature:*

By signing the consent section of this Patient Privacy 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 listed herein. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your prior approval.

Regulatory authorities may assess your information under the terms of the Regulated Health Professionals Act (RHPA) and for the defence of legal issues.

Our office will not disclose under any conditions your health or medical information to your insurer. In the event of such a request, we will inform you and if need be, forward the information to you for review and for your specific consent. When unusual requests are received, we will contact you for your
permission to release such information. We may also advise you if such a release is inappropriate.

You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, as well as the process.

Office Policy for missed/cancelled or rescheduled appointments.

Please note that our office needs at least 2 business days prior notice to cancel and or reschedule appointments. Any Cancellation, missed or rescheduled appointments not meeting the above criteria, could attract a charge of $100/- which will be payable by you.

Office policy for Unpaid balances and insurance payments

Whilst we do direct billing to all insurance companies, please note that any unpaid amount by the insurance company or any unpaid balances due, are immediately payable by you in the office. Please ensure that you are updated with your dental insurance policy to avoid any confusion.

Patient Consent

I have reviewed the above information, which explains how your office will use my personal information and the steps your office is taking to protect my information. I have also reviewed the office policy and consent with the same.

I know that your office has a privacy code, and I can ask to see the code at any time.

I agree that Dr. Prathana Davla can collect, use and disclose my personal Information.

Patient or Parent/Guardian Name:*

Patient or Parent/Guardian Signature:*