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 theimportance of protecting your personal information. We are committed to collecting, using and disclosing your personal informationresponsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is importantto us to provide this service to our patients.

In this office, Dr. Mark Parete 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 youhave 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 personal information is collected and we only share this with your consent;
storage, retention and destruction of your personal information complies with existing legislation, and privacy protectionprotocols;
our privacy protocols comply with privacy legislation, standards of our regulatory body,the Royal College of Dental Surgeons of Ontario, and the law.

Do not hesitate to discuss our policies with me or any member of our office staff.

Please be assured that every staff person in our office is committed to ensuring 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, wehave 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, efficient patient care and to identify and to ensure continuous high quality service
to assess your health needs, provide health care and to advise you of treatment options
to enable us to contact you and to establish and maintain communication
to offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally
to communicate with other treating health-care providers, including specialists and general dentists who are the referring dentistsand/or peripheral dentists
to allow us to maintain communication and contact with you to distribute health-care information and to book and confirmappointments
to allow us to efficiently follow-up for treatment, care and billing
for teaching and demonstrating purposes on an anonymous basis
to complete and submit dental claims for third party adjudication and payment

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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 Professions Act
to comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons ofOntario, including the delivery and/or review of patients’ charts and records to the College in a timely fashion for regulatory andmonitoring purposes
to permit potential purchasers, practice brokers or advisors to evaluate the dental practice
to allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability andquantify damages, if any
to prepare materials for the Health Professions Appeal and Review Board (HPARB)
to invoice for goods and services
to process credit card payments and 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 this Patient Consent Form, you have agreed that you have given your informed consent to thecollection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the useand/or disclosure of your personal information, we will seek your approval in advance.

Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA)for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of alegal issue

Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of arequest is made, we will forward the information directly to you for review, and for your specific consent

When unusual requests are received, we will contact you for permission to release such information. We may also advise you ifsuch a release is inappropriate.

You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of thatdecision, and the process.

Child Medical History Form