NOTICE OF COLLECTION OF PERSONAL INFORMATION AND CONSENT TO COLLECT
“We” and “our” mean the following optometric practice: Underhill Optometry
READ CAREFULLY BEFORE SIGNING: By signing this form, you consent to our collection of the information above
We collect, use and share your personal information for the following purposes: your ongoing eye care; to provide services to you; to understand your eligibility for benefits and/or services; to arrange payment for services; and as required by law.
The collection of this information is authorized by the Health Insurance Act, Optometry Act, Regulated Health Professions Act and Health Protection and Promotion Act.
We will take all reasonable steps to ensure that your personal information is treated confidentially and is only used for the purposes it was collected. We will take all reasonable steps to prevent unauthorized access, use or disclosure of your personal information.
You may obtain access to your personal information stored by us in accordance with the Personal Health Information Protection Act by making a written request to Underhill Optometry
If you would like to make a comment or complaint regarding the collection, use, or disclosure or handling of your personal information you may contact: Gillian Pengelly, firstname.lastname@example.org or 416-445-7490.
You also have the right to complaint to the Information Privacy Commissioner/Ontario, 1400-2 Bloor Street East, Toronto, ON M4W 1A8 (800-387-0073)
I have read the information on this form and DO consent to the above.