We are committed to protecting the privacy of our patients' personal information and utilizing all personal information responsibly and professionally. This document summarizes some personal information we collect, use and disclose. In addition to the circumstances described in this form, we collect and disclose personal information when permitted or required by law.
Contact information such as names, home addresses, telephone numbers and email addresses are collected and used for the following purposes:
- To open and update patient files.
- To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts.
- Process claims for payments or reimbursement from third-party health benefit providers and insurance companies.
- To send appointment reminders through our automated confirmation system "Intiveo."
- To send reminders to patients concerning the need for further dental examination or treatment.
- To send patient's information about practice or material.
Contact information is disclosed to third-party health benefit providers and insurance companies when a claim has been submitted for reimbursement or payment of all or part of the cost of dental treatment to the patient or dental provider.
Financial information is collected to make arrangements for the payment of dental services.
We collect information from our patients about their health history, their family health history, physical condition and dental, and dental treatments (collectively as "Medical Information"). Patient's medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.
Patient's medical/dental information is disclosed:
- To third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient's behalf.
- To other dentists and dental specialists, where we seek a second opinion, and the patient consented to us obtaining the second opinion.
- To dentists and dental specialists if the patient has been referred by us to another dentist or dental specialist for treatment, with their consent.
- To other dentists and dental specialists where those dentists have asked us, with the patient's consent, to provide a second opinion.
- To the health care professional such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment.
If we are ever considering selling all or part of our practice, qualified purchasers may be granted access as part due diligence process to patient information in order to verify information for potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.
Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest.
I consent to the collection, use and disclosure of my personal information as set out above.
I hereby assign benefits payable for the eligible claims to the provider responsible for submitting my claims electronically to the group benefits plan, and I authorize the insurer/ plan administrator to issue payment directly to the provider.