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Smiles On Bank Dental Office 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. Lama Ghantous 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. To help you understand how our office is protecting your personal information, 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 health and patient care

· To identify and ensure continuous high quality services in relation to the oral and maxillofacial complex and dental care generally

· To assess your health needs

· To advise you of treatment options

· To enable us to contact you

· To establish and maintain communication with you

· 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 efficiently follow-up for treatment, care, and billing

· 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

· 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 process credit card payments

· To collect unpaid accounts

· To assist this office to comply with all 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 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. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly to you for review, and for your specific consent. If unusual requests for information are received, we will contact you for permission to release such information. You may withdraw your consent for use and disclosure of your personal information, and we will explain the ramifications of that decision and the process. Do not hesitate to discuss our policies with any of our staff members. Please be assured that every dentist and staff person in our office is committed to ensuring that you receive the best quality dental care.

Patient Consent

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

I agree that Smiles On Bank can collect, use, and disclose personal information about

as set out in the information about the office’s privacy policy

Print name

Date

Signature

(Sign Here)

Clear Signature

Signature of Witness

(Sign Here)

Clear Signature

Privacy-Collection