Patient Consent Form

Patient Name

First Last

Legal Guardian

First Last

For Collection, Use, And Disclosure Of Personal Information By The Dental Office Of Dr Amardeep Sekhon Dentistry Professional Corporation

Privacy of your personal information is an important part of our office, providing you with quality care. We understand the importance of protecting your personal information. We are committed to collecting, using, and disclosing your personal information responsibly. We also try to be as open and transparent as possible about how we handle your personal information. It is important to use to provide this service to our patients.

In this office, Dr. Amardeep Sekhon acts as Privacy Information Officer.

All staff m, embers who come in contact with your personal information are aware of the sensitive nature of the information you have disclosed to us. They are trained in the appropriate uses and protection of your information.

Attached to this consent form, we have outlined what our office is doing to ensure that:

only necessary information is collected about you,
we only share your information with your consent, storage, retention, and destruction of your personal information comply with existing regulation and privacy protection protocols,
our privacy protocols comply with privacy legislation, standards of regulatory body, the Royal College of Dental Surgeons of Ontario, and the law,
all file cabinets are locked, and the office is secured with an alarm system,
no maintenance staff enters the office after hours,
computers are password-protected,
the landlord may not enter the promises without Dr. Sekhon's presence,
faxes are received in a confidential area.

Do not hesitate to discuss our policies with me or any member of our staff. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care.

How Our Office Collects, Uses, And Discloses Patient's Personal Information

Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how our office uses and discloses your 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,
to provide health care,
to advise you of treatment options,
to enable us to contact you,
to establish and maintain communication with you,
to offer and provide treatment, care, and services in relation to the oral and maxillofacial complex and dental care generally,
to communicate with other treating healthcare providers, including specialists and general dentists who are the referring dentists and peripheral dentists,
to allow us to maintain communication and contact with you to distribute healthcare information and to book and confirm appointments,
to enable us to efficiently follow-up for treatment, care, and bolling,
to complete and submit dental claims for third-party adjudication and payment,
to comply with legal and regulatory requirements, including the delivery of patient's 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 (RHPA),
to comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and 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 conduct an audit in preparation for 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 (HPARB),
to invoice for goods and services,
to process credit card payments,
to collect unpaid accounts,
to assist this office to comply with all regulatory requirements,
to collect unpaid accounts,
to comply generally with the law.

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

Regulatory authorities may access your information under the terms of the Regulated Health Professions Act (RHPA) (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under RHPA, and the defense of a legal issue.

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

When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate.

You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision and the process.

Patient Consent

Review of Information

I have reviewed the above information that explains how your office will use my personal information and your office's steps to protect my information. I know that your office has a Privacy Code, and I can ask to see the Code at any time.

Receipt of Form B

I have received form B - patient information sheet on access.

Download Form B

Regarding Privacy Policies

I agree that Dr. Amardeep Sekhon can collect, use and disclose personal information about me as set out above in the information about the office's privacy policies.

Appointments

I request and permit the staff of the Amardeep Sekhon Dentistry Professional Corporation to confirm my appointments by email, telephone, or text at the following numbers:

Allow Text

Yes
No

Email

Phone

Fees

I understand that there is a $50.00 fee for missed appointments and that 24 hours (1 business day) are required to make any changes or cancellations.

Signature*

Email

This field is for validation purposes and should be left unchanged.