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.
愛牙仕齒科致力於為您量身定制最佳的牙科服務。為了给我們的客人提供更好的口腔服務，所有治療費用請在服務結束時結清。
We pleased to offer the following payment options:
我們很高興為您提供如下付款選擇
Option 1 Non-assignment of benefits with payment in full.
選項一 全額付款
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.
全額支付治療費用，用現金、貸記卡、Visa或萬事通卡支付。我們會協助您提交保險索賠，保險公司的支票會在3到5個工作日寄到您府上。
Option 2 Assignment of benefits secured with your credit card.
選項二 轉讓保險金並提供備用信用卡信息
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.
我們接受您將牙科保險金轉讓給我們，並在服務結束時結清保險自負額和免賠額。如您有第二份牙科保險，我們會為您準備相關文件，方便您提交給保險公司。我們會預留您的信用卡信息，以用來結清任何30天內的沒有支付給我們的保險差價。如有任何收費，我們會事先告知並將收據郵寄到您府上。
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.
本人提供的所有個人以及病歷資料僅供診所醫療人員使用，所有資料會被保存在診所中，并受個人隱私條例的保護。
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.
本人以上提供所有病歷資料全部屬實，沒有刻意隱瞞任何有關資料，如對病歷表有任何疑問，本人隨時可以向醫生或診所職員詢問。本人允許診所醫生為本人進行必要的牙科診斷和治療，并允許診所醫生在必要時聯繫本人的家庭醫生以提供最合適的牙科治療。本人負責本人以及家屬所接受治療的費用。
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.
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 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.
