Privacy of your personal information is an important part of our office providing you with quality dental
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 the way we handle your personal information. It is important to
us to provide this service to our patients.
In this office, Dr. Robert vanGalen acts as a Privacy Information officer.
All staff members who come in contact with your personal 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.
Our 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 advise you of treatment s
- to enable us to contact you
- to establish and maintain communication with you
- to offer and provide treatment, care, and services in relationship to the oral and maxillofacial
complex and dental care generally
- to communicate with other treating health-care providers, including specialists and general dentists
who are the referring dentists and/or
- to allow us to maintain communication and contact with you to distribute health-care information and
to book and confirm appointments
- to allow us to efficiently follow-up for treatment, care and billing
- for teaching and demonstrating purposes 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'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
- 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 patients' 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
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 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 comply generally with the law
By signing 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 the 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 regulatory authorities under the terms of the Regulated Health
Professions act (RHPA) for purposes
of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the
defence of a legal issue.
Our office will not under any condition supply your insurer with your confidential medical history. In
the event this kind of a request is made,
we will forward the information directly to you for review, and for specific consent. When unusual
requests are received, we will contact you
for your permission to release such information. We may also advise you if such a release is
inappropriate. You may withdraw your consent
for use and disclosure of your personal information, and we will explain the ramifications of that
decision, and the process. In addition,
information older than 24 months may be stored offsite in a secure location.
Please do not hesitate to discuss our policies with any member of our office staff.
I have reviewed the above information that explains how the office will use my personal information,
and the steps the office is taking to
protect my information. I know that the office has a Privacy Code, and I can ask to see the Code at any
I agree that Dentistry in Dufferin and Simcoe (DDS) can collect, use and disclose personal information
set out above in the information about the office's privacy policies.