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Privacy of 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. David Gouett 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.
We have outlined what our office is doing to ensure that:
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Only necessary information is collected about you;
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We only share your information with your consent;
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Storage, retention and destruction of your personal
information complies with existing legislation, and privacy
protection protocols;
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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 Dr. David Gouett
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
information. To help you understand how we are doing that, we
have outlined here how our office using and disclosing your
information.
The office will collect, use and disclose information about
you for the following purposes:
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To deliver safe and efficient patient care
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To identify and to ensure continuous high quality service
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To assess your health needs and to provide health care
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To advise you of your treatment options
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To enable us to contact you
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To establish and maintain communication with you
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To offer and provide treatment, care and services in
relationship to the oral and maxillofacial complex and
dental care
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To communicate with other health treating providers,
including specialists and general Dentists who are the
referring Dentists and/or peripheral Dentists
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To allow us to maintain communication and contact you to
distribute healthcare information and to book and confirm
appointments. This may include sending e-mail/text reminders
to book and confirm appointments
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To allow us to efficiently follow-up for treatment, care and
billing
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To complete/submit predeterminations and dental claims for
third party adjudication and payment; to provide further
information that your insurer may request to aid I the
processing to predeterminations and claims
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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 and records to the provisions of the Regulated
Health Professions Act
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To comply with the 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 records to the College in a timely
fashion for regulatory monitoring purposes
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To permit potential purchasers, practise brokers or advisors
to evaluate the dental practice
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To allow potential purchasers or practice brokers to conduct
an audit in preparation for a practice sale
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To deliver invoices and to process credit card payments
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To collect unpaid accounts
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To assist this office in complying with all regulatory
requirements
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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 assessed 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 a legal issue.
Our office will not under any conditions supply your insurer
with your confidential medical history. In the event this kind
of request is made, we will forward the information directly
for your 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 a release is inappropriate.
You may withdraw your consent for use or disclosure of your
personal information, and we will explain the ramifications of
the decision, and the process.
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Patient Consent Submission
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✓
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I have reviewed the above information that explains
how your office will use my personal information,
and the steps your office is taking to protect my
information.
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✓
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I know that your office has a Privacy Code, and I
can ask to see the Code at any time.
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✓
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I agree that Dr. David Gouett Dentistry Professional
Corporation can collect, use and disclose personal
information about
[Patient Name Response] as set out
above in the information about the office's privacy
policies.
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Signature
[Digitally Endorsed by Patient]
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Print Name (Relationship to patient if signing for
child)
[Full Name Response]
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Date
[mm/dd/yyyy]
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Signature of Witness
[Digitally Endorsed by Witness]
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