privacy consent

We are committed to protecting the privacy of our patients’ personal information and to utilizing all person information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law.

We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers and e-mail addresses. (collectively referred to as “Contact Information”). Contact Information is 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.
  • To process claims for payment or reimbursement from third-party health benefit providers and insurance companies.
  • To send reminders to patients concerning the need for further dental examination of treatment.
  • To send patients informational material about our dental practice.

Contact 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 the dental treatment or has asked us to submit a claim on the patient’s behalf.

Financial information may be collected in order to make arrangements for the payment of dental services. In the case of an account being sent to a Collections Agency, any and all information required by them will be provided.

Patients Medical 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 are seeking a second opinion and the patient has consented to us obtaining the second opinion.
  • To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment.
  • To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion.
  • To other health care professionals 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 considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

Our information may be kept in physical form (files, models, etc.) in which case it is stored in a locked and secure location. Digital information may be stored on encrypted file servers in secure/access-controlled locations. Digital information is password protected and stored on systems that save audit trails in the event unauthorized access must be investigated. Our systems are protected by industry-standard IT security hardware and software measures.

We may enter into agreements with third-party providers specializing in data storage and protection. Sometimes that data is securely stored in the cloud, which may include locations outside of Canada. In those instances, only persons contractually obligated to secure and protect your data will be able to access that data. We will only enter into contractual agreements with providers that meet Canadian legal standards and requirements for storage and protection of personal health 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 their public interest.

I consent to the collection, use and disclosure of my personal information as set out above.

Date:
Patient – Print Name
Signature of Parent / Guardian / Foster Parent: