Patient Consent Form

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. MARIA ANA MARCELO 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 PATIENT’S 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
To identify and ensure continuous high-quality service
To assess your health needs
To provide health care
To advise you of treatment options
To enable us to contact you
To establish and maintain communication with you
To offer and provide treatment, care, and services in relationship to the oral and maxillofacial complex and dental care generally
To communicate with other treating healthcare providers, including specialists and general dentists who are 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, c are and billing
For teaching and demonstrating purpose on an anonymous basis
To complete and submit dental claims for third-party adjudication and payment
To comply with legal and regulatory requirements, including the delivery of patients chart 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 permit potential purchases, 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
To collect unpaid accounts
to assist this office comply with all regulatory requirements
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 purposed 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.

Patient Consent Privacy Act

I have received 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. Maria Ana Marcelo can collect, use

And disclose personal information about ( NAME of PATIENT)

as set out above in the information about the office’s privacy policies.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature(patient, parent or guardian)

Date

Name & Signature of witness

EDI SIGNATURE- ( for patient with INSURANCE ONLY)

I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorized the communication of information related to the coverage of services described to the named dentist.

This authorization shall continue in effect until the undersigned revokes the same.

Name and Signature Of patient, parent or guardian

Date

Your information will be encrypted.