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We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances in this form, we also collect, use and disclose personal information when permitted or required by law.

Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.

Patients’ Medical Information is disclosed for the following purposes:

To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf

·To other dentists and dental specialists where we are seeking a second opinion and the patient has consented to us obtaining the second option.

·To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment

·To other healthcare professionals, such as physicians, if the patient, with their consent, has been referred by us to the other healthcare professional for either a second opinion or treatment.

If we are ever considering selling all or part of our dental practice, qualified, potential purchasers may be granted access, as part of the due diligence process, to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest.

I, the undersigned acknowledge that Royal Oak Smiles is not a party to the contract of my insurance. It is between myself, my employer, and the insurance company. All charges not paid by my insurance company is my responsibly regardless of non-payment. The Royal Oak Family Dentistry team will try their upmost best to confirm maximums, frequencies, limitations, waiting periods, and exclusions. But, I, understand it is ultimately my responsibility. Any unpaid balances not attached to a signed payment agreement past 90 days will result in 3rd party collections.

Insurance

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Direct Billing is a courtesy we offer to our patients and in order to ‘Direct Bill’ your insurance provider, we require a credit card on file for any outstanding amounts owing after your insurance provider has paid their portion. I hereby agree to the Financial Policy of Royal Oak Smiles as outlined above and authorize Royal Oak Smiles to apply any outstanding balance on my account, not covered by my insurance provider, to the credit card listed below:

*Your card will not be charged if full payment on account was made day of services rendered OR if written financial agreement was made/abided by.

*A financial agreement will not arranged unless a valid credit card is on file.

*We DO accept cash or cheque as a form of payment but REQUIRE a card on file for security purposes if you wish for us to direct bill to your insurance.

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