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 in this form, we also collect, use and disclose personal information when permitted or required by law.
Information is collected such as names; home and work addresses; home, work, and cell phone numbers, and e-mail addresses (referred to as “Contact Information”.) Contact information is collected and used for the following purposes:
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.
We collect information from our patients about their health history, family health history and their dental history. (Collectively referred to as “Medical Information”.) Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.
Patients’ Medical Information is disclosed for the following purposes:
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/our personal information as set out above.