Patient Privacy | Dr. Judith Buys and Associates

Judith Buys Dentistry Professional Corporation

Patient Constent FormFor Collection, Use and Disclosure of Personal Information

As of January 1, 2004, the Personal Information and Electronic Documents Act (PIPEDA) will come into force for all commercial activities in Canada, and that includes Dentists. Our office has always protected the personal information of all our patients in an ethical manner but because of this new act we must have signed documentation in every patients chart. Without this signed consent our office will be unable to treat your dental concerns.

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.

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. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care.

Our privacy protocols comply with privacy legislation, standards of our regulatory bodies, the Royal College of Dental Surgeons of Ontario, the College of Dental Hygienists of Ontario and the law. Storage, retention and destruction of your personal information comply with existing legislation and privacy protection protocols.

The office of Dr. Judith Buys and Associates will collect, use and disclose information about you for the following purposes:

to deliver safe and efficient patient care
to advise you of treatment options
to enable us to contact you
to provide dental treatment
to communicate with other health-care providers, including specialists (endodontists, orthodontists, periodontists, oral surgeons, TMJ specialists) and general dentists who are the referring dentists and/or peripheral dentists, Peterborough Regional Health Centre and Five Counties Children’s Centre
to book and confirm appointments with you
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 process credit card payments
to collect unpaid accounts
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 assist this office to comply with all regulatory requirements
to comply 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 Profession Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario and/or the College of Dental Hygienists 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 this kind of a request is made, 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.