PATIENT CONSENT FORM: COLLECTION, USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATON
Privacy of your personal health information is an important part of our office providing you with quality dental care.
We understand the importance of protecting your personal health information. We are committed to collecting, using, and
disclosing your personal health 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 to provide this service to our patients.
In this office, Dr. Michael Laureola is the contact person for personal health information-related matters.
All staff members who come in contact with your personal health information are aware of the sensitive nature of the information
that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.
How Our Office Collects, Uses and Discloses Patient’s Personal Information
This office will collect, use and disclose information about you for the following purposes:
To deliver safe and efficient patient care
To identify and ensure continuous high-quality service
To assess your health needs
To provide health care
To offer and provide treatment options
To enable us to contact you
To establish and maintain communication with you
To offer and provide services in relation to the oral and maxillofacial complex and dental care general dentists and/or peripheral dentists
To allow us to book and confirm appointments with you
To allow us to efficiently follow up for treatment, care, and billing
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 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 the member of the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patient’s charts and records to the College 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 deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any
To prepare materials for the Health Professions Appeal and Review Board (HPARB)
To process credit/debit card payments
To collect unpaid accounts
To assist this office to comply with all regulatory requirements
To comply generally with the law
By signing below, you have agreed that you have given your informed consent to the collection, use, and/or disclosure of your personal information for the purposes listed.
If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.
Your personal health information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA).
You may withdraw your consent for the use or disclosure of your personal health information at any time.
I have reviewed the above information about how your office will use my personal health information, and the steps that your office is taking to protect my information.
I agree that Dr. Michael Edmond Laureola Dentistry Professional Corporation can collect, use and disclose personal information as set out above in the information about the office’s privacy policies.