Clear Dental is committed to providing quality care and taking all possible steps in protecting the privacy of the patients and their personal information. All personal information collected will be used in a reasonable, professional manner. The purpose of this document is to summarize the personal information that will be collected, used, and disclosed by Clear Dental. In addition to what is stated in this document, Clear Dental will also collect, use, and disclose personal information when required to by law. All members of Clear Dental ensure strict compliance with the regulatory and ethical guidelines set by the Alberta Dental Association and the Health Information Act Legislation.
Clear Dental understands the importance of privacy regarding personal information and is committed to collecting, using, and disclosing the information in a responsible manner. This office ensures that:
The information collected from our patients (names, home address, work address, telephone numbers, email addresses) referred to as contact information serves the following purpose at Clear Dental:
This information will be disclosed to third party providers and insurance companies where the patient has designated a claim to be submitted on their behalf.
Financial information could be collected to make payment arrangements for dental services.
Health history, family health history, physical and dental treatments and conditions are collected and used to determine or diagnose dental conditions and provide dental treatment. It is also used to ensure the medical safety of the patient while undergoing treatment The disclosure of medical information could happen if:
Dentists are regulated by the Alberta Dental Association and College which regulates the records and interviews staff as part of their office regulatory activities for the benefit of public interest.
Standard headshots, videos, and intra-oral photography/radiography are all used as a part of the Clear Dental routine examination process. These portions of the exam are utilized in the following ways:
Clear Dental takes the control of infection extremely seriously and has therefore made every effort to obtain and use the best sterilization machines/services as possible which meet and/or exceed the regulations set forth by the Alberta Dental Associate and College.
Clear Dental works hard in order to provide the patient with a personalized dental treatment plan that is best-suited for the patient’s needs. The treatment cost estimates given to you in your treatment plan will be honored for 90 days from the date the treatment plan was presented. Beyond this time period costs are subject to change.
For your convenience, Clear Dental is able to direct bill on the patient’s behalf. As Clear Dental is a third party, in order to take on the responsibility of direct billing we require to keep a copy of your insurance card information on file as well as all Patient Information to be fully completed and correct. It is also the responsibility of the patient to predetermine coverage limits with their insurance provider prior to treatment. If a predetermination of benefits has not been received or brought in to Clear Dental, Clear Dental is authorized to collect a 30% copay at the time of treatment. If any balance further remains once payment has been received from the insurance company, Clear Dental will contact the patient to authorize the remaining payment to be made. If payment is not made after 30 days of initial attempt to notify patient about the outstanding balance, Clear Dental has the right to charge collection costs (30% of outstanding balance + sales tax) and reasonable attorney fees incurred in attempting to collect on outstanding balance.
If you wish to do non-assignment (Not Direct Billing), all payments must be made in full to Clear Dental at the time of treatment. For your convenience, we accept cash, debit, VISA, and Mastercard. After payment has been made, all necessary paperwork will be provided to submit to the insurance company.
Policy Out of respect for all patients as well as the staff of Clear Dental, if a patient is to arrive more than 15 minutes late to their appointment, Clear Dental reserves the right to decline to see you. The appointment may be rescheduled. If you are unable to make it to an appointment, please let us know you would like to cancel more than 24 hours prior to the scheduled appointment time. If a patient continuously cancels within 24 hours of their designated appointment time, Clear Dental has the right to refuse service to that patient.
I acknowledge that I am aware of the reasons for my information being taken and understand that refusing to provide any of this information will result in the inability of the dentist to properly administer my oral care.
I understand and consent to all of the above. I also understand that I can revoke my consent at any time, but if I decide to do so it must be in writing and signed by myself (patient or guardian) and presented to the Clear Dental clinic. I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the dentists at Clear Dental.
