I authorise my dentist to release my medical records, including, but not be limited to, radiographs (x-rays), reports, charts, medical history, photographs, findings, plaster models or impressions or intra-oral scans of teeth, prescriptions, diagnosis, medical testing, test results, billing, and other treatment records in my dentist’s possession (“Medical Records”):
to other licensed dentists or and organisations employing licensed dentists, dental specialists, dental technicians and dental laboratories, its representatives, employees, successors, assigns, and agents for the purposes of investigating and reviewing my medical history as it pertains to dental treatment with products from third parties and;for patient education within this dental clinic – I understand that my medical records may be used at this dental clinic for in surgery patient education, and will be used without identifying information, such as my name, but I understand that it is possible that someone may recognise me.for educational and research purposes – I understand that my medical records may be used for publication in a journal, textbook, as part of a display or information leaflet or on an open access website, which may be seen by members of the general public as well as medical professional. I understand that my medical records will be used without identifying information such as my name, but I understand that it is possible that someone may recognise me.
I understand that use of my Medical Records may result in disclosure of my “individually identifiable health information” as defined by the Health Insurance Portability and Accountability Act (“HIPAA”). I hereby consent to the disclosure(s) as set forth above. I will not, nor shall anyone on my behalf seek legal, equitable or monetary damages or remedies for such disclosure. I acknowledge that use of my Medical Records is without compensation and that I will not nor shall anyone on my behalf have any right of approval, claim of compensation, or seek or obtain legal, equitable or monetary damages or remedies arising out of any use such that comply with the terms of this Consent.
