Personal Information Consent
We are committed to protecting the privacy of our patient’s personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted by law.
We collect information from our patients such as names, home addresses, work addresses, home phone number, work phone number, 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 services, to process credit card payments, or to collect unpaid accounts
- To process claims for payment or reimbursements from third-party health benefit providers and insurance companies
- To send reminders to patients concerning the need for further orthodontic treatment
- To send patients informational material about our orthodontic 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 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 payment of dental services.
We collect information from our patients about health history, their family health history, physical condition, and dental treatments. (Collectively referred to as “Medical Information”) Patient’s Medical information is collected and used for the purpose of diagnosing dental conditions and providing orthodontic treatment.
Patient’s 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 orthodontic treatment or has asked us to submit a claim on the patients behalf
- To dentists and dentist specialists, where we are seeking a second opinion and the patient has consented to us obtaining a second opinion
- To other dentists and dental specialists if the patient, with 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 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 ever 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.
Dentist and Orthodontists 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 the public interest.
You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the office. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat or to continue treating you if you revoke this consent.
I consent to the collection, use and disclosure of my personal information as set out above. I further consent to include electronic communication between the office and yourself, as well as 3rd party insurance and other dental and health professionals as needed to communicate and make treatment decisions. The electronic communication can and may include non-encrypted email, fax and text messaging.
Your information is being submitted securely and will not be shared or sold. I consent to receive electronic correspondence.
Free Online Consultation!