PATIENT CONSENT FORM: COLLECTION, USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION

Privacy of your personal health information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal health information. We are committed to collecting, using and disclosing your personal health information responsibly. We also try to be as open and transparent as possible about the way we handle your personal health information. It is important to us to provide this service to our patients.

In this office, Dr. Ahmad is the contact person for personal health information related matters.

All staff members who come in contact with your personal health 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 health information complies with existing legislation, and privacy protection protocols;
 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.

How Our Office Collects, Uses and Discloses Patients’ Personal Health Information

Our office understands the importance of protecting your personal health 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 personal health information about you for the following purposes:
 to deliver safe and efficient patient care
 to identify and to ensure continuous high quality service
 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 dentists
 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
 for teaching and demonstrating purposes on an anonymous basis
 to complete and submit dental claims for third party adjudication and payment
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 records to the College in a timely fashion for regulatory and monitoring 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 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 payments
 to collect unpaid accounts
 to assist this office to comply with all regulatory requirements
 to comply generally with the law

At our office, all professional dentistry services are performed by licensed members of the Royal College of Dental Surgeons (the “Dental Professionals”), and all institutional health care services (e.g. dental cleanings) are performed independently by Scottsdale Family Hygiene Services Inc. under the clinical supervision and control of Dental Professionals, in a cost sharing arrangement. Ahmad Dentistry Professional Corporation and Scottsdale Family Hygiene Services Inc. are independent corporations providing independent services but for ease of administration they may render joint invoices for their respective services. By signing this form, the undersigned acknowledges that they have read and understood the information and disclosure set forth herein prior to any services being provided to the undersigned.

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 health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal health information, we will seek your approval in advance.

Your personal health 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.

You may withdraw your consent for use or disclosure of your personal health information at any time.