Our mission at ToothMatters Dental is to provide excellence in dentistry that meets your individual needs. In order to reduce the cost of providing dentistry to our clients, payment is expected at the time of service.
We pleased to offer the following payment options:
Option 1 Non-assignment of benefits with payment in full.
Payment is made in full by Cash, Interact, Visa, or MasterCard with non-assignment of your dental benefits. We will process your dental insurance claim for you and have the cheque sent directly to you within 3-5 business days.
Option 2 Assignment of benefits secured with your credit card.
We will accept assignment of your primary dental benefits and collect the co-payment at the time of service. We will provide you with a copy of any secondary insurance claims for you to submit. A credit card will be kept on file to process any payment not reimbursed to us within 30 days. In case of any charges, a courtesy notice will be provided and a receipt will be mailed to you.
hereby assign payment of my dental benefits directly to ToothMatters Dental Care.
我授權將我的保險金轉讓並直接支付給愛牙仕齒科ToothMatters Dental Care。
I hereby authorize ToothMatters Dental Care to process payment to my credit card of any outstanding balance occurred during the course of dental treatment to keep my account current within 30 days.
我授權愛牙仕齒科ToothMatters Dental Care在治療結束後30天內，用我的信用卡結清我賬戶內的余額。
I understand all information I have supplied will be used only for my dental care within this office in compliance with Personal Privacy Act standards.
I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment that are necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary.
Privacy of your personal health information is an important part of our office providing you with quality
dental care. We understand the importance of protecting your personal health information. We are commit 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, doctors act as the Privacy Information Officer. 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.
Our office understands the importance of protecting your personal health information. To help you 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 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 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 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’ 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 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
- 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.
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 ToothMatters Dental Care can collect, use and disclose personal health information about
as set out above in the information about the office’s privacy policies.
Please note: If English is not my primary language, I have had the opportunity to have this interpreted for me and I fully understand the words and concepts expressed here.