Dental Office Personal & Medical Information Consent Form / Personal Information & Protection Act
We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal 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, home & work telephone numbers, and email addresses. (Collectively referred to as “contact information”). Contact information is collected and used for the following purposes:
- To open & update patient files.
- To invoice patients for dental services, to process credit card payments, or to collect unpaid
- To process claims for payment or reimbursement from third-party health benefit providers and
- To send reminders to patients concerning the need for further dental examinations or 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 dental treatment or has asked us to submit a claim on the patients’ behalf.
Financial information may be collected in order to make arrangements for the payment of dental services.
We collect information from our patients of their health history, family health history, physical conditions, and dental treatments. (Collectively referred to as “Medical Information”) Patients’ medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.
Patients’ Medical Information is disclosed:
- To third party health benefit providers and insurance companies where the patients 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 their behalf.
- To other dentists and dental specialist, where we are seeking a second opinion and the patients 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 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 a second opinion or treatment.