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I, {Name (First):3.3} {Name (Last):3.6} (D.O.B.: {Date of Birth:12}), hereby authorize the release of my dental records to:

Chapel Hill Dental
3400 ch. Innes Rd., Orléans, ON K1W 0G1
Tel.: 613.424.4241 Fax: 613.424.8887
Email: smile@chapelhilldental.ca

Please forward all recent x-rays by email to Chapel Hill Dental at your earliest opportunity, together with the following information to assist them going forward:

Date of last COE
Date of last Recall Exam
Date of last Bite Wings
Date of last Panoramic Image

Thank you for your cooperation.

Compliance with the Personal Health Information Protection Act (PHIPA)

Privacy of your personal health information is extremely important to us, and 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.

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.

This office will collect, use and disclose personal health 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 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 peripheral dentists
-to allow us to maintain communication and contact 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 communicate with your insurer(s) about your dental coverage and to complete and submit dental claims for 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 permit potential purchasers, practice brokers and advisors to evaluate the dental practice
-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 and collect unpaid accounts
-to assist this office to comply with all regulatory requirements
-to comply generally with the law

By checking this box, you acknowledge 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 above. 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.

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

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Compliance with the Personal Information Protection and Electronic Documents Act (PIPEDA)

The Canadian Personal Information Protection and Electronic Documents Act (PIPEDA) (and equivalent provincial legislation) requires that consent be obtained prior to the collection and use of all personal information. The personal information obtained herein as well as additional information obtained during your visits at our office will be used for the purposes reasonably associated with providing you with dental care.

These purposes include: contacting you about your dental needs as well as your upcoming appointments, submitting insurance claims to your insurer on your behalf, discussing your dental health with other specialists or health professionals as may be required, and communicating important information to you about our office.

We anticipate that the personal information collected will be restricted to your name, gender, date of birth, contact information (including mailing address), and insurance information. Additional personal information may be collected from time to time.