Please read the following consent forms and sign at the base of the document.
PIPA (Privacy) Consent
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 patient files.
• To invoice patients and/or legal guardians or persons financially responsible for patient accounts, for dental services, to process credit card payments or to collect unpaid accounts.
• To process claims for payment or reimbursement from third-party benefit providers, insurance companies and government agencies.
• To send reminders to 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 from whomever has been written as financially responsible for the account.
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 all third party benefit providers, insurance companies and government agencies where a claim is being submitted for reimbursement or payment of all or part of the cost of dental treatment.
• To other dentists and all other health care providers, where further information and/or discussion is required.
• To other dentists and dental specialists if the patient 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 to provide a second opinion.
• To other health care professionals such as physicians if the patient has been referred by us to the other health care professional for either a second opinion or treatment.
• Where we are seeking and/or providing information to the following: laboratories, radiology centres, hospitals, etc.
• To include the following when necessary, such as: videos, pictures, slides, etc, for educational purposes.
• A student and/or other dental practitioner may observe for educational purposes.
• Should any of the above information be requested, authorization is being granted to transmit electronically via e-mail or fax.
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 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 interests.
In addition, should you wish to grant South Calgary Oral and Maxillofacial Surgery permission to disclose and/or release any and all medical information and/or financial information on your behalf to a family member, significant other or friend, please indicate so below:
By signing below, I consent to the collection, use and disclosure of my personal information as set out above.
Patient/Legal Guardian Signature