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 summaries 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 addresses, work addresses, home/work telephone numbers, photographs and email 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 prevent insurance fraud.
• To send reminders to patients concerning the need for further dental examination or treatment.
• To send patients informational material about our dental practice.

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, family 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 dentist 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 physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment.
• To agents of the law (i.e. lawyers, police officers, etc.) where the information is required for legal matters.

If we are ever considering selling all or part of our dental practice, qualified potential purchases may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. We will take steps to ensure that the prospective purchaser safeguards all personal information. Dentists are regulated by ADA&C 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.