New Patient Information

For Collection Use and Disclosure Information

Privacy of a patient is an important part of our office. We understand the importance of protecting personal information. We are committed to collecting, using, and disclosing your personal information. In this office, Dr. Shasha 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 you 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 every legislation and privacy protection protocols
• Our privacy protocols comply with privacy legislation standards of our body of the royal college of Dental Surgeons of Ontario, and the law

Do not hesitate to discuss our polices with me or any member of our office staff. Please be assured that every staff person in our office is committed to ensure 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
• To identify and to ensure continuous high quality service
• To asses 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 the relationship to the oral and maxillofacial complex and dental care generally
• To communicate with other treating health care providers, including specialist and general dentists who are the referring dentists and/or peripheral dentists
• To allow us to maintain communication and contract with you to distribute healthcare information and to book and confirm appointments
• To allow us to efficiently follow-up with treatment care and billing
• For teaching and demonstrating purposes on an anonymous basis
• To complete and submit dental claims for third party adjunction 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 protection act.
• To comply with agreements/undertakings entered 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.
• To permit potential purchasers, practice brokers of advisors to evaluate the dental practice
• To allow the potential purchasers, practice brokers or advisors to conduct in preparation for a practice sale
• To deliver your charts and records to the dentist's insurance carrier to enable the insurance company to asses liability and quantity changes, if any
• To prepare materials for the Health Professionals Appeal and Review Board (HPARB)
• To invoice for goods and services
• To process credit card payments
• To collect unpaid accounts
• To assist this office to comply with the regulatory requirements
• To comply generally with the law

By signing the consent section of the Patient Consent Form, you have agreed that you have given your informed consent to the collection use and/or disclosures or 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. You information might be accessed by the regulatory authorized under the terms of the Regulated Health Professionals Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling it's manors under the RHPA, and for the defence of a legal issue. Our office will not under any conditions supply your insurer with your confidential medial history. In this event, at this time, where a request is made, we will forward the information directly to you for review and for your specific consent. When usual 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 review your consent for the use of disclosure of your personal information and we will explain the ramifications of that decision, and the process.