Patient Consent Form: For Collection, Use and Disclosure of Personal Information
Privacy of your personal information is an important part of our office 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 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 patients.
In this office, Dr. Mandana Nikoui acts as the Privacy Information Officer.
All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all 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 personal information complies with existing legislation, and privacy protection protocols; our privacy protocols comply with privacy 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 me or any member of our office staff.
Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care.
How Our Office Collects, Uses and Discloses Patients’ Personal Information
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 and disclosing your information.
This office will collect, use and disclose information about you for the following purposes:
- to deliver safe and efficient patient care and to identify and to ensure continuous high quality service
- to assess your health needs, to advise you of treatment options and to provide health care
- to enable us to contact you and to establish and maintain communication with you to offer and provide treatment, care and services in relationship to the oral and maxillofacial
- to communicate with other treating health-care providers, including specialists and general dentists who are the 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
- to allow us to efficiently follow-up for treatment, care and billing and 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 Professions Act
- to comply with agreements/undertakings 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
- for teaching and demonstrating purposes on an anonymous basis
- to permit potential purchasers, practice brokers or advisors to evaluate the dental practice
- to allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
- to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any
- to prepare materials for the Health Professions Appeal and Review Board (HPARB)
- to invoice for goods and services, to process credit card payments and to collect unpaid accounts
- to assist this office to comply with all regulatory requirements and to comply generally with the law
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/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 a legal issue.
Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of a request is made, we will forward the information directly to you for review, and for your specific consent.
When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate.
You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.
Office Policies
- I will be responsible for all charges incurred by my child regardless of my insurance coverage and am aware there is no direct relationship between our office and your insurance company. Any reimbursement will be made directly to you according to the terms of your policy.
- I am aware that PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. Contactless Payment: We will be accepting VISA or Mastercard only for payments. We will take your credit card information by phone upon your arrival. Please note all financial information is shredded after payment is made, we do not keep any credit card information on file.
- I understand appointments are considered confirmed when scheduled (We will be happy to provide you with a reminder phone call or email). In the event that an appointment cannot be kept, I will notify the office at least 2 business days in advance, so that it can be rescheduled.
Consent
The permission of parent or guardian is necessary for dental treatment of a minor.
- I understand that all the above information I have given is correct and accurate, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I consent to the performing of dental procedures agreed to be necessary or advisable for my child.
- I also consent that my child’s radiographs, dental and facial photographs and dental models be kept in our files and be used for treatment planning and follow-up, patient/parents education and medical/dental lectures.
- I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information.
I know that your office has a Privacy Code, and I can ask to see the Code at any time.
- I agree that Dr. Mandana Nikoui, Dentistry Profession Corporation can collect, use and disclose personal information about my child as set out above in the information about the office’s privacy policies.
- I have read and fully understood the policies of this office as stated above.
