THIS FORM IS TO CONFIRM YOUR AUTHORIZATION TO USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR A SPECIAL PURPOSE.

I give my authorization to use or disclose my protected dental information. I give this authorization voluntarily. I understand that I may revoke this authorization at any time by giving written notice to the privacy officer at your office. However, I understand that I may not revoke this authorization for any actions taken before receipt of my written notice to revoke this authorization . In addition, I understand  that if  I am giving this authorization  as a condition of obtaining insurance coverage, and I revoke this authorization, insurance company has a right to consent to my claims under the insurance policy. I understand that under most circumstances a dental care provider may not condition treatment, payment, enrollment, eligibility, for benefits on my signing this authorization. However, I understand that signing an authorization that permits the use and/ or disclose  of my protected health information  for research purpose, may be a condition of my treatment if I am undergoing research- related treatment. Also, I may be required to sign an authorization if my treatments provided sole for the purpose of creating protected health information for disclosure to a third party. And  under some circumstances, a health plan may condition my enrollment in a health plan or my eligibility  for benefits on my providing an authorization permitting the health plan to make enrollment and eligibility determination. I understand that the  information disclosed under this authorization may be redisclosed by the recipient. Fedral privacy rules may not protect the privacy of my health information once the recipient rediscloses my health information. I have had the chance to read and think about consent of this authorization form and I agree with all statements made in this authorization. I understand that, by signing this form,  I am confirming my authorization  for use and/or disclosure of protected health information  described in this form  with the people  and/or organizations named in this form

if this authorization form is signed by a personal representative for the individual patient: