Patient Privacy Consent Form

Patient Privacy Consent

This office will collect, use and disclose information about you for the following purposes:

- To deliver safe and efficient care, to establish and maintain communication with you and to advise you of treatment options.
- To permit potential purchasers, practice brokers or advisors to evaluate the practice.
- To comply with agreements/undertaking entered into voluntarily by the member with governing bodies, including the delivery and/or review of patient’s charts and records in a timely fashion for regulatory and monitoring purposes.
- To communicate with other treating health-care providers, including specialists and referring doctors.
- To identify and to ensure continuous high-quality service.
- To comply with legal and regulatory requirements, including the delivery of patient’s charts and records to governing bodies in a timely fashion, when required, according to the provisions of the Regulated Health Profession Act.
- To allow us to efficiently follow-up for treatment, care, and billing.
- To assess your health needs and enable us to contact you.
- To allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments.
- To complete and submit claims for third-party adjudication and payments.
- To provide health care.
- To offer and provide treatment, care, and services.
For teaching and demonstrating purposes on an anonymous basis.
- To allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale.
- To comply generally with the law.
- To invoice for goods and services.
- To deliver your charts and records to the office’s insurance carrier to enable the insurance company to assess liability and quantify damage, if any.
- To assist this office to comply with all regulatory requirements.
- To process credit card payments and to collect unpaid accounts.
- To prepare materials for the Health Professions Appeal and Review Board (HPARB).

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.
Please note that this office is equipped with security cameras in common areas and operation rooms for security purposes and your own safety. By signing this Patient Consent Form, you have confirmed that you have been notified of this matter.
Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professional Act (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, to review, and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may 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 that decision, and the process.

Contact Us

If you have any questions about this Patient Privacy Consent, You can contact us:
By email: info@yongeandfinchdental.com
By visiting this page on our website: https://www.yongeandfinchdental.com/contact