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. Preet Chowdhary 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.
Attached to this consent form, we have outlined what our office is doing to ensure that:
• Only necessary information is collected about you
• We only share your information with your consent
• Storage, retention and destruction of your personal information complies with existing legislation
and privacy protection protocols
• Our privacy protocols comply with privacy legislation, standard of our regulatory body, the Royal
College of Dental Surgeons of Ontario, and the Law
Our office understands the importance of protecting your personal information. To help you understand
how we are doing that 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 patient care
• To identify and ensure continuous high quality services
• To assess your health needs
• To provide health care
• To advise you of treatment options
• To enable us to contact you
• To establish and maintain communication with you
• 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 dentists and/or peripheral dentist
• To allow us to maintain communication and contact with you to distribute health care
information and to book and confirm appointments
• To allow us to efficiently follow-up for treatment, care and billing

• 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 of Ontario, including the delivery and/or review of patients’ charts and record to the college in a timely fashion for regulatory and monitoring purposes
• 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 prepare materials for the Health Professions Appeal and Review board (HPARB)
• To invoice for goods and services
• To process credit card information
• 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 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. Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professional 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 a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of a request 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 if such release is appropriate.

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

I know that your office has a Privacy Code, and I can ask to see the Code at any time.

I agree that Dentistry @ Mt Pleasant Square can collect, use and disclose personal information about
the office’s privacy policies.

Financial Policy

1. Payment in full is due when services are rendered.
2. Payment may be made by Cash, Cheque, Credit Card or Third Party Financing.
Billing Process

As a courtesy, we will gladly file dental claims for you. Once you provide your dental insurance, we call your insurance company to verify your benefits. The information we receive from your insurance company are only an estimation of coverage and not a guarantee. Your insurance policy is a contract between you and the insurance company; therefore we cannot guarantee payment of any claims or accept the responsibility of negotiating with your insurance companies or other persons. We are not responsible for providing you with limitations, exclusions, and provisions determined by your insurance company. Your estimated co-pay and deductible are due and payable at the time of service.

If any insurance company does not cover or pays only a portion of the bill or rejects your claim, you will receive a statement and the balance is your financial responsibility for services rendered. Conversely, if your insurance company pays above the projected estimation, you will receive a credit in that amount which may be drawn as a refund upon request or applied to further treatment. If your insurance company has not paid on your claim with 60 days, the full balance will automatically be transferred to you and will be due upon billing.

Authorization
I understand and guarantee all the information on the new patient registration forms was completed correctly to the best of my knowledge and understand it is my responsibility to inform the Dentist of any changes in my health and medication. I authorize the Dentist and the Staff of Dentistry @ Mount Pleasant Square to perform any necessary services include taking digital radiographs (x-rays), study models, photographs or any other diagnostic aids deemed needed by the Dentist to make a thorough diagnosis. I have read and understand the billing process for Dentistry @ Mt Pleasant Square. I also assign all insurance benefits to Dentistry @ Mt Pleasant Square.