Patient Consent Form: For Collection, Use And Disclosure Of Personal Information
Privacy of your personal information is an important part of our Clinic providing you with quality dental 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.
At SCODE Dental Clinic, Dr. Anurag Singh acts as the Privacy Information Officer.
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.
Attached to this consent form, we have outlined what our clinic 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 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 clinic staff.
Please be assured that every staff person in our Clinic is committed to ensuring that you receive the best quality dental care.
How Our Clinic Collects, Uses and Discloses Patients’ Personal Information
Our clinic understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our Clinic is using and disclosing your information.
This clinic will 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 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 in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
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 information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.
Your information may be accessed by regulatory authorities under the legal terms for the defense of a legal issue.
Our Clinic will not under any conditions supply your insurer with your confidential medical history. In the event this kind of a request is made, we will forward the information directly to you for review, and for your specific consent.
When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release in inappropriate.
You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.
I have reviewed the above information that explains how your Clinic will use my personal information, and the steps your Clinic is taking to protect my information.
I know that your Clinic has a Privacy Code, and I can ask to see the Code at any time.
I agree that Scode Dental Clinic can collect, use and disclose personal information about as set out above in the information about the Clinic’s privacy policies.