(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

I authorize Contemporary Dentistry to use and disclose the protected health information described.

This authorization for release of information covers all past, present, and future periods of healthcare in this facility.

This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payments, or other purposes as I may direct.

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to consent a claim.

I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.