RELEASE OF IDENTIFYING HEALTH INFORMATION

I authorize Kevin Mosmen, DMD, doing business as The Dental Difference and/or The Sedation Dentistry Center of New Jersey, to release health information identifying me, including if applicable, information about HIV infection or AIDS, information about substance abused treatment, and information about mental health services to health professionals and facilities deemed worthy, by Dr. Mosmen, during the course of treatment at his office. This permission will remain in effect until such time that I choose to terminate it in writing.

Examples of released information may include, but are not limited to:

  1. Consultations with other dentists and physicians who have or are providing care
  2. Pharmacies for health and prescription services
  3. Other:

It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization.

If you sign this authorization you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked.

When your health information is disclosed as provided in this authorization, State and/or Federal laws often govern what happens with this received information.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION
AS DESCRIBED IN THIS FORM.

If you are signing as a personal representative of the patient describe your relationship to the patient and the source of your authority to signing this form.