Personal Information Consent Form
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, work telephone numbers, and e-mail addresses (collectively referred to as ‘Contact Information’). Contact information is collected and used for the following purposes:
- To open and update files
- To invoice patients for dental services, to process payments or to collect unpaid accounts
- To process insurance claims for our patients both electronically via CDAnet and manually when applicable
- To send reminders to patients concerning the need for further dental examination or treatment
- To send patients information 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 to submit a claim on the patients’ 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 known 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 a second opinion.
- To other dentists and dental specialists if the patient, with their consent, has been referred to us by the other dentist or dental specialist for treatment.
- To other dentists or 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 of the patient, with their consent, has been referred to us by other healthcare professionals to 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 inspect our records and interview our staff as part of its regulatory activities in the public interest.
I authorize release to my dental benefits plan administrator and the Canadian Dental Association, information contained in claims submitted electronically, when applicable. I also authorize the communication of information related to the coverage of services described to Dr. Shackleton Prof. Corp.
I consent to the collection, use and disclosure of my personal information as set out above. This authorization shall continue in effect until the undersigned revokes the same.
