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DENTAL
IMPLANTS Dental Dental © R.E. Leigh |
* 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. 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. Patients’ Medical Information is disclosed: * To third-party health benefit providers and
insurance companies where the patient has submitted a claim 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 ____________________ ___________________________ ___________________________ 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. Storage and Destruction of Personal information
We are required by legislation
and regulation to keep records containing personal information for specified
periods of time.
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