I understand my complete dental record may include information that I have provided to Sage Dental related to my mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse. By signing this form, I agree and acknowledge that: I am not required to sign it to receive dental treatment and any payment, enrollment or eligibility for benefits will not be conditioned upon my signing. I have the right to inspect and receive a copy of the information used and disclosed pursuant to this Authorization. I have the right to revoke this Authorization at any time by writing to Sage Dental, of my intent to revoke this Authorization. Information disclosed pursuant to this Authorization may be redisclosed by the recipient and no longer be protected by federal or state privacy laws. If I refuse to sign this form, it does not stop disclosure of my health information that is otherwise permitted by law without my specific authorization or permission My authorized representative will be required to provide legal documents and may be required to provide proof of identity and authority to sign on my behalf. Copy of this Authorization (including electronic copy or email) may be used for the disclosure of the above information. I am entitled to a copy of this Authorization after signing it. I have read this Authorization and agree to the release, use and disclosure of my PHI (as described above).

SIGNATURES

COMPLETE THIS SECTION ONLY IF MINOR PATIENT’S RECORDS HAVE THE HEALTH INFORMATION related to certain types of reproductive care, sexually transmitted diseases, drug, alcohol or substance abuse, and mental health treatment. If Minor patient’s dental records contain the above information then Minor will need to sign below.