Authorization for Use and Disclosure of Protected Health Information

Name of Practice: ___Yuma Dentistry 4 Kids __________________ (the “Practice”)

By my signature below, I affirm, as a patient of the Practice named above OR as the parent or legal
guardian of a minor child that is a patient of the Practice named above (the “Patient”), that I
authorize the Practice: (i) to capture photographic or video images of the Patient (the “Images”);
(ii) to reproduce, use, and disclose the Images, with or without the Patient’s name; (iii) to publicize
the fact that dental services were provided to the Patient; (iv) to reproduce and publish any
testimonials the Patient provides regarding the Practice (collectively referred to herein as the
“Information”); and (v) to secure copyright registration for any materials that incorporate the
Information, at the election and sole expense of the Practice. The authorization is given to the
Practice listed above, for disclosures to any persons, without limitation, who may view the
Information in printed or digital form in promotional materials including social media or Internet

The purpose of this authorization is to permit the Information, including Images, to be used for
marketing of the Practice, and I explicitly consent to the use of Information for advertising and
marketing activities to promote the Practice. I acknowledge and agree that no compensation will be
provided for the use of the Information.

Expiration and Revocability:
If Patient is signing on his or her own behalf, this authorization expires when the Patient informs
the Practice that he or she is no longer a patient of the Practice. If Patient is signing on behalf of a
minor child, this authorization expires when the Patient reaches the age of majority, but the
authorization remains valid for protected health information already used or disclosed until revoked
by the Patient who has attained majority. However, I understand that protected health information
already used or disclosed prior to any revocation may no longer be protected. I understand that I
may revoke this authorization at any time by notifying the Practice by Certified Mail, return receipt
requested, but that revocation will only affect uses and disclosures initiated after the date notice is
received by the Practice. Upon receipt of the notice of revocation, the Practice will make
reasonable efforts to remove protected health information from social media platforms over which
it has control, but cannot guarantee removal from all sites. I understand and explicitly
acknowledge that the Internet allows for wide sharing and forwarding of information, and that the
Practice cannot control all re-disclosure of information.

No Effect on Treatment:
This authorization is voluntary. I understand that the Practice cannot condition treatment of the
Patient on whether I sign this Authorization, and that my decision not to sign will not influence or
affect the Patient’s treatment in any way.