We understand the importance of protecting your personal information. All team members who come into contact with your records are aware of the sensitive nature of the information you have disclosed to us. They are all trained in the appropriate use and proper protection of your information.

In this office Dr. Sukhman acts as the privacy Officer.

Outlines of what the consent entails and what our office is doing to ensure your privacy are as follows:

• Only necessary information is collected about you
• We only share your information with your consent
• Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols as outlined by the Royal College of Dental surgeons of Ontario

Do not hesitate to discuss our policies with Dr. Sukhman or any member of our team.

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 to ensure continuous high quality service
• to assess your health needs and provide care
• to offer, advise and provide treatment options, care and services in relationship to the oral and maxillofacial complex and dental care
• to establish and maintain communication with you, including booking and confirming appointments
• to communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists to allow us to efficiently follow-up for treatment, care and billing
• for teaching and demonstrating on an anonymous basis
• 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 with 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 and/or 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 Professionals Appeal and Review Board
• to process credit card payments and collect unpaid accounts
• to assist this office to comply generally with the law and all necessary regulatory requirements.

By agreeing to the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.

Your information may be accessed by the regulatory authorities under the terms of the Regulated Health Professionals Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue.

Our office will not under any conditions supply your insurer with your confidential medical history. In the event that this request is made, we will forward the information directly to you for review, and for your specific consent.