Acknowledgment of Receipt of Notice of Privacy Practices and Consent for Use and Disclosure of Health Information

Patient Giving Consent

My personal health information is private and confidential. I understand that my doctor and his
staff work very hard to protect my privacy and preserve the confidentiality of my PHI.

I understand that my doctor and his staff may use and disclose my PHI to help provide health
care to me, to handling billing and payment, and to take care of other healthcare operations.
There will be no other uses and disclosures of this information unless I permit it. However, I
understand that sometimes the law may require the release of this information without my
permission.

My doctor has a detailed document call the “Notice of Privacy Practices”. It contains more
information about the policies and practices protecting my privacy. My doctor may update this
notice. If I ask, my doctor or his staff will provide me with the most current notice and the
current notice will always be posted at my doctor’s office.

I authorize the release of information to the following individuals who may participate in my
care following dental treatment:

My signature below indicates that I have been given a current copy of my doctor’s “Notice of
Privacy Practices”. I understand that I have the right to read and ask any questions regarding
the “Notice” before signing this agreement.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.