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Thank you for choosing us as your dental care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy which we require that you read and sign prior to any treatment.

GENERAL:
Understand that regardless of any insurance status, you are responsible for the balance due on your account. You are responsible for any and all professional services rendered. This includes but is not limited to: dental fees, surgical procedures, tests, office procedures, medications and also any other services not directly provided by the dentist.

MISSED APPOINTMENTS:
Unless we receive notice of cancellation 48 hours in advance, you will be charged $100.00. Please help us service you better by keeping scheduled appointments.

INSURANCE:
Please remember your insurance policy is a contract between you and your insurance company. We are not a party to that contract.
As a courtesy to you, our office provides certain services, including a pre-treatment estimate which we send to the insurance company at your request. It is physically impossible for us to have knowledge and keep track of every aspect of your insurance. It is up to you to contact your insurance company and inquire as to what benefits your employer has purchased for you. If you have any questions concerning the pre-treatment estimate and/or fees for service, it is your responsibility to have these answered prior to treatment to minimize any confusion on your behalf.
Please be aware some or perhaps all of the services provided may or may not be covered by your insurance policy. Any balance is your responsibility whether or not your insurance company pays any portion.

PAYMENT:
FULL PAYMENT is due at the time of service. If insurance benefits apply, ESTIMATED PATIENT CO-PAYMENTS and DEDUCTIBLES are due at the time of service, unless other arrangements are made.

Option One
You may pay in full at the time of service, after which we will submit your dental claim on your behalf and have the insurance company issue the cheque directly back to you.

Option Two
Direct Billing from D.R. Dental Clinic – Assignment of Benefits from your insurance company will require a valid credit card number to be left on file. Our office will not allow any balance to extend past 45 days from date of service. Unpaid balance over 30 days old will be subject to monthly interest of 1.5% (APR 18%). If payment is delinquent, the patient will be responsible for payment of collection, attorney’s fees, and court costs associated with the recovery of the monies due on the account.

I have read, understand and agree to the terms and conditions of this Financial Agreement. I hereby authorize payment directly to D.R. Dental Clinic for services rendered, otherwise payable to me. I authorize the release of any information relating to my dental claims through this office.

At D.R. Dental Clinic, 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.
Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law. We also use video camera for public protection against theft and vandalism in the waiting room and hallways. 

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 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 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 hereby grant permission to D.R. Dental Clinic and its representatives to photograph and video me, and otherwise capture my image, and to make recordings of my voice. I further grant to D.R. Dental Clinic and its representatives the right to reproduce, use, exhibit, display, broadcast and distribute these images and recordings in any media now known or later developed for promoting, publicizing or explaining D.R. Dental Clinic and its activities and for administrative, educational or research purposes. Photographs, video images and voice recordings are the property of D.R. Dental Clinic.

Privacy, Financial & General Information
I certify that I have read, understood and accurately completed the personal information to the best of my knowledge and have not knowingly omitted any information. This information has been reviewed with me. I authorize the dentist and his/her auxiliary staff to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental care.

Consent for Collection, Use and Disclosure of Personal Information.
I agree that D.R. Dental Clinic has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I consent the office to send communicate by phone, text, email and mail as I provided. I have been provided with a copy of the consent form and agree that personal information may be collected, used and disclosed as set out in the Privacy Policy at this dental office and is in accordance with the Personal Health Information Protection Act, 2004.