Privacy Notice and Consent – Hatheway Orthodontics

PRIVACY NOTICE & CONSENT

Privacy notice, consent acknowledgement, and signatures.

Step 1 of 2

Our office understands the importance of protecting your personal health information. To help you understand how we are doing that, we have outlined below how our team is collecting, using and disclosing your information. Please do not hesitate to let us know if you have any questions.

For more detailed information about our personal information practices, please see our Privacy Policy which can be found on our website or by asking one of our clinic representatives. We will collect, use and disclose personal information about you (including personal health information) 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 communications with you
To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex, orthodontic care and/or 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 (including through our call centres and website portal)
To allow us to efficiently follow-up for treatment, care and billing
For teaching and demonstrating purposes on an anonymous basis
Access my dental benefits plan administrator and the CDA, information contained in electronic claims and information related to the coverage of services described.
To complete and submit dental claims via CDA electronic or post mail submission for third party adjudication and payment
To comply with legal and regulatory requirements, including the delivery of patients' charts and records to the applicable dental regulatory college in a timely fashion, when required, according to applicable law
To comply with agreements, I undertakings entered into voluntarily by a dentist or orthodontist with the applicable dental regulatory college, including the delivery and/or review of patients' charts and records 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 analyze, develop and improve our product services and offerings, including analyzing patient and aggregate data to better understand our user base for business and income purposes
To deliver your charts and records to the dentist or orthodontist's insurance carrier to enable the insurance company to assess liability and quantify damages, if any
To prepare materials for any applicable health profession disciplinary or review board
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
Otherwise with your consent or as permitted or required by law

Consent Confirmation(Required)

I confirm that I have read and understood the terms outlined above.

Preferred location(Required)

Patient's Name(Required)

Date(Required)

Patient/ Responsible Party Signature(Required)

Signature

Your personal information may also be accessed by the applicable dental regulatory college as permitted or required by law.
By signing the consent section below, you agree that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes listed above. You may withdraw your consent for use or disclosure of your personal information at any time.

PATIENT CONSENT

I have reviewed the above information that explains how the office will use my personal information. I hereby authorize the team to collect, use and disclose personal information about me as set out above. I understand that my personal information will be collected from me or my other health providers or other persons with my consent. My personal information may be disclosed by the team to my health insurer(s) or other third party payer(s) to determine coverage and process payment and to any other person and for any other purpose with my consent, or as permitted or required by law. I understand that my orthodontist may at some time recommend a consultation with another specialist or could need to communicate with my dentist or other professionals. regarding my case. I hereby authorize the team to communicate, discuss and/or share information from my file, with other professionals in a manner that he/she feels is necessary.

The file containing my personal information will be held by the offices or on its servers or those of its service providers. Authorized employees who require it for the purposes of their duties will have access to this file. To the extent provided by applicable law, I may request to have access to and the correction of my personal information, or to obtain additional information on the practices with respect to the handling of my personal information by contacting drbob@hathewayortho.ca

I know that if I am dissatisfied with the manner in which my request for access or correction of my personal information has been addressed, I can contact the privacy commissioner in my province. I know that the clinic has a Privacy Policy, and I can ask to see the Privacy Policy at any time.

I also consent to the taking of x-rays, photographs and other necessary records before, during and after treatment for the purposes of planning, performing and evaluating treatment.

Patient's Name(Required)

Date(Required)

Patient/ Responsible Party Signature(Required)

Signature

PRIVACY NOTICE & CONSENT

PATIENT CONSENT

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