Personal Information Consent Form /Personal Information & Protection Act
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 described in this form, we also collect, use and disclose personal information when permitted or required by law.
We collect information from our patients such as names, home addresses, home & work telephone numbers, and email addresses. (Collectively referred to as “contact information”). Contact information is collected and used for the following purposes:
- To open & update patient files.
- To invoice patients for Optometric services, to process credit card payments, or to collect unpaid accounts.
- To process claims for payment or reimbursement from third‐party health benefit providers and insurance companies.
- To send reminders to patients concerning the need for further optometric examinations or treatment.
- To send patients material about our optometric practice.
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 optometric treatment or has asked us to submit a claim on the patient’s behalf.
Financial information may be collected in order to make arrangements for the payment of optometric services.
We collect information from our patients of their health history, family health history, physical conditions, and Optometric treatments. (Collectively referred to as “Medical Information”) Patients’ medical information is collected and used for the purpose of diagnosing ocular conditions and providing optometric treatment.
Patients’ Medical Information is disclosed:
- To third party health benefit providers and insurance companies where the patients has submitted a claim for reimbursement or payment of all or part of the cost of optometric treatment or has asked us to submit a claim on their behalf.
- To other Optometrists and Ophthalmologists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion.
- To other Optometrists and Ophthalmologists if the patient, with their consent, has been referred by us to the other Optometrist or Ophthalmologist for treatment.
- To other Optometrists and Ophthalmologists where those Optometrists and Ophthalmologists have asked us, with the consent of the patient, to provide a second opinion.
- To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for a second opinion or treatment.
If we are ever considering selling all or part of our optometric 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.
Optometrists are regulated by the Ontario Optometric Association and College of Optometrists of Ontario which may inspect or records and interview our staff as part of its regulatory activities in the public interest.