PATIENT CONSENT FORM

FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Privacy of your personal information is an important part of THE PERIO CENTRE 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 open and transparent as possible about the way we handle personal information. It is important to us to provide this service to our patients.

In this office, Dr Adam Ohayon, acts as the Privacy Information Officer.

All staff members who encounter personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate use and protection of your information.

Attached to this consent form, we have outlined what The Perio Centre 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 the existing legislation and privacy protection protocols
Our privacy protocols comply with the 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 any member of our staff.

Please be assured that every staff member in our office is committed to ensuring that you receive the best quality of dental care.

The Perio Centre understands the importance of protection your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information.

The office 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 of service
To assess your health records
To advise you of treatment options
To enable us to contact you
To establish and maintain communication with you
To officer and provide treatment, care and services in relationship to oral maxillofacial complex and dental care generally
To communicate with other health-care providers, including specialists and general dentists who are 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
For us to efficiently follow-up for treatment, care, and billing
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 Professional Act
To comply with agreements/undertaking 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 permit potential purchasers, practice brokers or advisors to conduct and audit in preparation for a practice sale
To deliver your charts/records/photos to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any
To prepare material for the Health Professions Appeal and Review Board (HPARB)
To invoice for goods and services
To process credit card payments
To collect unpaid accounts
To assist this office to comply with all regulatory requirements
To comply generally with the law

By signing the consent section of the 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 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, and for the defense of legal issues.

You may withdraw your consent for use and disclosure of your personal information at any time. At that time, we will explain the ramifications of the decision

PATIENT CONSENT

I have reviewed the above information that explains how The Perio Centre will use my personal information, and the steps your office is taking to protect my information