A Full Spectrum
of Dental Services

DR. LEVITIN Dentistry Professional Corporation

PATIENT CONSENT FORM:

PERSONAL INFORMATION

Privacy of your professional 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 patient.

In this office, Dr.A. Levitin acts as the privacy information officer.
All staff members who come in con t with personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate used 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 legislation, and privacy protocols protection;
Our privacy; protocols comply with privacy legislation, standard of our regulatory body, the Royal collage of Dental Surgeons of Ontario, and the law.

Do not hesitate to discuss our policy with me or any members of our office 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 Personal Information?

Our office understands the importance of protecting your personal information. To help you to understand how we are doing that, we have outlined here how our office is using and disclosing 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, and 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 service in relationship to the oral and maxillofacial complex and dental care generally;
To communicate with other treating health care, provide, including specialists and general dentists who are the referring dentists and /or peripheral dentists;
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;
To complete and submit dental claims for the third party adjudication and payment;
To complete with legal and regularity requirements, including the delivery of patient charts and records to the Royal Collage OF Dental Surgeons Pf Ontario in timely fashion, when require, according to the provisions of the Regulated Health Professions Act(RHPA);
To comply with agreements/undertaking entered into voluntarily by the members with the Royal Collage of Dental Surgeons of Ontario, including the delivery and/or review of patients' charts and records of the Collage in a timely fashion for regulatory and monitoring purposes;
For teaching and demonstrating purpose on an anonymous basis.
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 to the insurance carrier to enable the insurance company to assess liability and quantify damages, if any;
To prepare material for the health professions Appeal and Review Board (HPARB);
To invoice for goods and service
To process credit card payments;
To collect unpaid accounts;
To assist the=is office to comply with all regularity requirements;
To comply generally with the law.

By singing the consent section, of this Patient Consent Form, you have agreed that you have given your informed consent to collection, use and /or disclosure of your personal information for the purpose 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 be accessed by regulatory authorities under the term of the Regulated Health Professions Act (RHPA) for the purpose of the Royal Collage of Dental Surgeons of Ontario fulfilling its medicate, under the RHPA, band for the defense of a legal issue.

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.

Patient Consent

I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information. - I know that your office has a privacy Code, and I can ask to see the code at any time.

I agree that Dr. A. Levitin Dentistry Professional Corporation, and its successors, can collect use and disclose personal infromation about as set out above in the information about the office's privacy policies.