We are committed to protecting the privacy of our patients’ personal information and to utilizing personal information in a professional and responsible manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstance in this form, we also collect, use and disclose personal information when permitted or required by the law.
We collect information from our patients such as names, home address, work addresses, home/cellular telephone numbers, work telephone numbers and email addresses. (Collectively referred to as “Contact Information”) Contact information is collected and used for the following purposes:
Contact information is disclosed to insurance companies, third party health benefit providers where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment and has authorized us to submit a claim on their behalf. Financial information may be collected 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 referred 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 for the following purposes:
Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of regulatory activities in public interest.
I consent to collection, disclosure and use of my personal information as set out above.