* For
information purposes only:
IMPLANT SMILE CENTER
PERSONAL INFORMATION CONSENT FORM
We are committed to protecting the privacy of our
patients’ personal information and to utilizing all
personal information in a responsible and professional manner. This document
summarizes some of
the personal information that we collect, use and disclose. In addition to the
circumstances described
in this form, we also collect, use and disclose personal information when
permitted or required by law.
We collect information from our patients such as names,
home address, work address, home
telephone
numbers, work telephone numbers, and e-mail addresses (collectively referred to
as
"Contact Information").
Contact Information is collected and used for the following purposes:
* To open and update patient files.
* To invoice patients for dental services, to process
credit card payments, or to collect unpaid accounts.
* To process claims for payment or reimbursement from
third-party health benefit providers and insurance companies.
* To send reminders to patients concerning the need
for further dental examination or treatment.
* To send patients informational material about our
dental practice or information relating to dental health.
Contact Information is disclosed to third-party health
benefit providers and insurance companies where
the
patient has submitted a claim for reimbursement or payment of all or part of the
cost of dental
treatment,
or has asked us to submit a claim on the patient’s behalf.
Financial information may be collected in order to make
arrangements for the payment of dental
services.
We collect information from our patients about their
health history, their family health history, physical
condition, and dental treatments (collectively referred to as "Medical
Information"). Patients’ Medical
Information is collected and used for the purpose of diagnosing dental
conditions and providing dental
treatment.
Patients’ Medical Information is disclosed:
* To third-party health benefit providers and
insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of
dental treatment, or has asked us to submit a claim on the patient’s behalf.
* To other dentists and dental specialists, where we
are seeking a second opinion and the patient has consented to us obtaining the second opinion.
* To other dentists and dental specialists if the
patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment.
* To other dentists and dental specialists where those
dentists have asked us, with the consent of the patient, to provide a second opinion.
* To other health care professionals such as a
physician if the patient, with their consent, has been referred by us to the other health care professional for either a
second opinion or treatment.
If we are ever considering selling all or part of our
dental practice, qualified potential purchasers may
be
granted access, as part of the due diligence process, to patient information in
order to verify
information
important to the potential sale. If this occurs, we will take steps to ensure
that the
prospective purchaser
safeguards all personal information.
Dentists are regulated by the Alberta Dental
Association and College, which may inspect our records
and interview our staff as part of its regulatory activities in the public
interest.
I consent to the collection, use and disclosure of my
personal information as
set out above.
____________________
___________________________
___________________________
Date
Print Name
Signature
R.E. LEIGH Professional Corp. ®
Our
Personal Information Procedures
We have
appointed a Privacy Officer as our principal advisor and issues manager
regarding personal information
protection. On your behalf, our staff is trained in personal information
protection. We review our information collection
procedures and consent forms on an ongoing basis, and we ensure that any
contractors we hire who might have
access to your personal information also take steps to protect the privacy of
your personal information.
At the Implant Smile Center we have a privacy policy in place for patients and
employees.
The Personal Information Protection Procedures below tell you how we fulfill the
commitment to patients in our Privacy
Policy at the Implant Smile Center Dental Health Clinic.
Protection of Your Personal
Information in Our Records
Our records containing your
personal information are stored in a secure place.
Our electronic records are stored on hardware that is secure. Passwords are used
on all of our computers.
We take care to protect screen monitors from public viewing in the office.
Paper records are transferred outside our office in sealed envelopes by secure
methods and with reputable carriers.
Telephone discussions with patients in the office are carried on with
sensitivity to protecting personal information.
Electronic information is transferred in secure files, and sent anonymously
wherever possible.
We do not share your personal information outside our office for any marketing,
promotional, publicity, educational or
research purposes without your consent.
Our staff is trained to handle your information only through the protective
measures outlined in our privacy procedures.
If we hire consultants or contractors who might have access to any of your
personal information, we will take steps to
ensure that the consultant or contractor takes steps to protect the privacy of
your personal information.
Storage and Destruction of
Personal information
We are required by legislation
and regulation to keep records containing personal information for specified
periods of time.
We keep your records for a maximum of 10 years from your last service, even if
you move from our office.
We destroy personal information in paper records by shredding it. We destroy
electronic personal information by deleting it.
When discarding hardware, we make sure the hard drive is destroyed.

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