HERITAGE DENTAL HYGIENE PRIVACY POLICY CONSENT FORM

 

The privacy of your personal information is an important part of our office providing you with quality dental care.  At Heritage Dental Hygiene, 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 that we provide this service to our patients.  

 

In this practice, Amie Banting is our Privacy Information Officer. All contracts, contracted and employed members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to use.  They are all trained in the appropriate uses and protection of your information. Our Privacy Policy and Information Practices ensure that:

 

• Only necessary information about you is collected

• We only share information with your consent

• Storage, retention, and destruction of your personal information complies with existing legislation and privacy protection protocols

• Our privacy protection complies with privacy legislation, standards of our regulatory body, the College of Dental Hygienists of Ontario and /or the Royal College of Dental Surgeons of Ontario, and the law.  

 

Heritage Dental Hygiene will collect, use and disclose information about you for the following purposes:

 

• To deliver safe and efficient care, identifying and ensuring continuous high-quality service

• To advise you of all treatment options

• To enable us to contact you and maintain communication with you, including distributing health-care information and to schedule, change and confirm appointments

• To offer and provide treatment, care and services in relation to the oral and maxillofacial complex and dental care generally

• To communicate with other treating health-care providers, including physicians, pharmacists, referring general dentists and specialists

• To allow us to efficiently follow-up for treatment, care, and billing

• Intra and extraoral photography chairside is obtained during procedures for documentation and record-keeping.  This photography may need to be provided to your dental insurance company or other health care providers for the purpose of collaborating on your treatment

• For teaching and demonstration on an anonymous basis

• For marketing and promotional material on an anonymous basis 

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• 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 and /or the College of Dental Hygienists 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 staff with the Royal College of Dental Surgeons of Ontario and /or the College of Dental Hygienists of Ontario, including the delivery and /or review of patients charts and records to the college (s) in a timely fashion for regulatory and monitoring purposes.  

 

Do not hesitate to discuss our policies with the administration or any member of our office staff

Thank you

 

CLIENT CONSENT

 

I have reviewed the above information that explains how Heritage Dental Hygiene will use my personal information, and the steps your practice is taking to protect my information. 

 

I know that Heritage Dental Hygiene has a Privacy Policy, and I can ask to see this policy at any time. 

 

I agree that Heritage Dental Hygiene can collect, use and disclose personal information about myself and /or family as set out above in the information about the office’s privacy policies. 

 

I understand that Heritage Dental Hygiene and the dental providers, health providers who treat clients will provide me with accurate information regarding the treatment I will receive. I have the option to request or decline the recommended treatment, but I will be informed of the clinical treatment that I require.  

 

I am aware that Heritage Dental Hygiene and dental providers, health providers who treat me will make me aware of the cost of treatment.  I have the option to discuss the fees openly with my provider and make him or her aware of my financial expectations in relation to the cost of Dental Hygiene Treatment.  

 

I have reviewed Heritage Dental Hygiene’s policy above about the collection, use, and disclosure of personal information, steps taken to protect the information and my right to review my personal information. I understand how the Privacy Policy applies to me.  I have been given a chance or will be given a chance to ask any questions I have and they have or will be answered to my satisfaction.   

 

I understand that I have agreed to receive notice that I am due for dental hygiene services.  I will receive newsletters from Heritage Dental Hygiene that pertain to oral health information, office closures, oral education events, and important information that Heritage Dental Hygiene feels pertains to me. When I receive newsletter correspondence I have the option to opt-out but I understand that if I do so I may not be aware of important information pertaining to Heritage Dental Hygiene’s business operations and oral health information.  

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If you were asked to read, review and consent to our Privacy Policy to schedule an appointment and you agree with our Policy Policy click back to the booking appointment screen and check the box to consent. 

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