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, work
addresses, home telephone numbers, e-mail addresses, birthdays, and other
government, corporate and/or personal data (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 dental services, to process credit card payments, or to
collect unpaid accounts.
•
To
process claims for payment or reimbursement from third party health benefit
providers and insurance companies.
•
To
send reminders and/or phone patients concerning the need for further dental
examination 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 patient’s behalf.
Financial
information may be collected in order to make arrangements for the payment of
dental services.
We
collect information from our patients about their health history, their family
health history, physical condition, 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 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.
•
To
other dentists and dental specialists, where we are seeking a second opinion
and the patient 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 or dental specialist 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
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.
Dentists
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.
I consent to the collection, use and disclosure of my personal
information as set out above.
___________________
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