PATIENT CONSENT FORM FOR USE AND DISCLOSURE OF PERSONAL INFORMATION
Protecting Your Privacy is Important to Us.
We at Bathurst Centre Dental Care (BCD) recognize and are committed to the importance of protecting your personal information. All staff members who come in contact with your personal information are aware of the sensitive nature of the information you have disclosed to us, and are trained in appropriate uses and protection of that information.
We will be as open as possible about the way we handle your personal information, and will collect, use and disclose it as responsibly as possible. Please do not hesitate to discuss with us our policies.
Why is the Information Collected, Used and Disclosed?
- To asses your health needs and provide dental care
- To enable us to contact you for treatment and care
- To process billings, credit card payments and to collect unpaid accounts
- To communicate with other treating health care providers, including specialists who are the referring dentists
- For teaching and research purposes on an anonymous basis
- For potential discussion with the Ethics Committee on an anonymous basis
- To complete and submit medical 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 and PHIPA (Personal Health Information Protection Act)
- To comply generally with the law
Your Rights with Respect to this Consent:
By signing this 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 above. If a new Purpose arises for the use/disclosure of your personal information; we will seek your consent in advance. We will never disclose your information to any advertiser. We 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 for your specific consent. When unusual requests for your information are received, we will contact you for permission to release such information, and inform you if such a release is inappropriate.
You may withdraw your consent for use or disclosure of your personal information at any time. Your revocation of this consent must be in writing to the clinic Manager. Note that your revocation of the consent is not retroactive, and therefore does not affect uses or disclosures we may already have made according to your prior consent.
PATIENT CONSENT
I have reviewed the above information that explains how Bathurst Centre Dental (BCD) will use, disclose and protect my personal information.
I agree that BCD can collect, use and disclose my personal information as set out above in the summary of the clinic’s privacy policy.