Patient Consent Form

Collection, Use and Disclosure of Personal Health Information

Privacy of your personal health information is an important part of our office providing you with quality dental care. 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 health information. It is important to us to provide this service to our patients.

In this office, Dr. Wid Mohamad 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.

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 health information complies with existing legislation, and privacy protection protocols;
• our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law. Do not hesitate to discuss our policies with me or any member of our office staff.

How our office collects, uses, and discloses patients’ personal health information

• to offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally
• to advise you of treatment options
• to establish and maintain communication with you
• 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
• 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 patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes
• 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 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 health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your
personal health 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) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its
mandate under the RHPA.

You may withdraw your consent for use or disclosure of your personal health information at any time.

Patient Consent

I have reviewed the above information that explains how your office will use my personal health information, and the steps your office is taking to protect my information. I agree that Tooth Harmony Dental can collect, use and disclose personal health information as set out above in the information about the office’s privacy policies.