Patient Consent Form

Patient Consent

Privacy of your personal information is an important part of our office providing you with quality dental claims. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibility. 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 parents.

In this office Adel Rofael acts as Privacy Information Offices.

All staff members who come in contact with your personal information are aware of the sensitive nature if the information that you have disclosed with us. They are trained in the appropriate uses and protection of your information.

Attached to this consent form, we have outlined what our office 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 persona information complies with existing legislation & privacy protocols.

  • Our privacy protocols comply with privacy legislations, standards of your regulatory boy, the Royal College of Surgeons of Ontario & the law.

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

Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using & disclosing your information.

The office will collect, use & disclose information about you for the following purposes:

  • To deliver safe & efficient patient care.

  • To identify & ensure continuous high-quality service.

  • To assess your health needs & provide health care: to advise you of treatment options:

  • To enable us to contact you, to establish & maintain communication with you.

  • To offer & provide treatment, care & service in relationship to the oral & maxillofacial complex & to book & confirm appointments.

  • To allow us to efficiently follow up for treatment, care and billing.

  • To complete & submit dental claims for third party adjudication & payment.

  • To comply with legal & regulatory requirements, including delivery of patients charts & records to the Royal college of Dental Surgeons of Ontario in timely fashion. When required: according to the provisions of the Regulated Health Professions act.

  • To comply with agreements/undertakings entered into voluntarily by the member of the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patient’s charts & records to the College in a timely fashion for regulatory & monitoring purposes.

  • To permit potential purchases, practice brokers, or advisors to conduct in audit in preparation for a practice sale.

  • To deliver your charts your charts & records to the dentist’s insurance carrier to enable the Insurance company to assess liability & quality damages, if any.

  • To prepare material for the Health Professions Appeal; & Review Board (HPARB)

  • To invoice for goods and services.

  • To process credit care payments, to collect unpaid accounts.

  • To assist this office to comply with regulatory requirements.

  • To comply generally with the late.

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/o disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure for your personal information, we will seek your approval in advance.

Your information will not under any conditions supply your Insurer with your confidential medical history. In the event this kind of request made; we will forward the Information directly to you for your review & for your specific consent.

When unusual requests are reviewed, we will contact you for permission to release such information. We may also advise you if such release is inappropriate.

You may withdraw your consent for use or disclosure of your personal information & we will explain the ramifications & decisions & the process.

I have reviewed the above information that explains how your office will use any personal information & the steps your office is taking to protect my information.

I know that your office has a Privacy Code & I can see the code anytime.

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