Dentistry on 14 | PATIENT PRIVACY CONSENT FORM | Dentistry on 14
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PATIENT PRIVACY CONSENT FORM

FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Privacy of your personal health information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal health 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 health information. It is important to us to provide this service to our patients.
In this office, Dr. Ayesha Jabeen acts as the Privacy Information Officer.
All staff members who come in contact with your personal health 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 health information complies with existing legislation, and privacy protection protocols.
  • our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, 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 of our office is committed to ensuring that you receive the best quality of dental care.

HOW OUR OFFICE COLLECTS, USES AND DISCLOSES PATIENT’S PERSONAL INFORMATION

Our office understands the importance of protecting your personal health information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information. This office will collect, use, and disclose personal health 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
  • To 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 relationship to the oral and 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 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/or review of patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes
  • To allow consultants or advisors to conduct an audit and assist in beneficial office management processes.
  • To deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and ligibility and satellite dental offices.
  • To prepare materials for the Health Professions Appeal and Review Board (HPARB)
  • To invoice for goods and services
  • To process credit card payments
  • 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 health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal health information, we will seek your approval in advance.
Your personal health information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of
Ontario fulfilling its mandate under the RHPA.
Our office will not under any conditions supply any one with your confidential documents. In such event
a request will be made, and we will forward the information directly to you for review and for your
specific consent .If any unusual requests are received, we will contact you for permission to release
information and we may also advise such a release as inappropriate. You may withdraw your consent for
use or disclosure of your personal health information at any time.

Patient Consent

I have reviewed the above information that explains how your office will use my personal health information, and the steps your office is taking to protect my information.
I agree that Dr. Ayesha Jabeen can collect, use, and disclose personal health information about (Patient’s name) as set out above in the information about the office’s privacy policies.

Since phase 2, and having reopened our office, we couldn't be happier to be connecting with our patients! We are taking the utmost precautions to provide a safe Covid free environment. Face shields, air purifiers, and limiting the number of patients to those that have appointments are just some of the new policies we have implemented. After every set of patients, we're dedicating time to properly sanitize the rooms, instruments and the waiting area, to ensure safety for the next set of patients. Please call us today for a free consultation!
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