This document and all information contained in it, is intended to assist individuals and organizations in understanding and complying with the Federal HIPAA Privacy and/or Security Rules. It is intended to provide initial guidance in developing documents necessary to achieve HIPAA compliance. Users of this document should tailor the information contained in it as necessary to complete and institutionalize their own operational policies and procedures as they apply to their individual organizational operations. This document and the information contained in it does not constitute legal advice. It is also not a substitute for legal or other professional advice and must not be construed as such. This document or the information contained in it does not constitute HIPAA compliance.

This document and the information contained in it is for the sole use of the licensed user, and the license holder’s single organization. It can not be sold, or sub-licensed or distributed outside the user’s single organization. Use of this document and the information in it is conditioned upon the user’s continued compliance with the Use Agreement and Disclaimer agreed to by the user at the time of licensing. The user of this document is solely responsible for the accuracy and appropriateness of all content contained in it. Users must consult with their own legal counsel for advice regarding the application of the law and this document as it applies to the HIPAA regulations and the decisions necessary to achieve HIPAA compliance. This document should undergo review and approval by the user’s organization’s legal counsel prior to being instituted.

I authorize Seung H Baek DDS Inc to use and disclose my medical information for the purposes of Treatment, Payment and Health Care Operations. Treatment includes activities performed by a health care provider, nurse, office staff, and other types of health care professionals providing care to you, coordinating or managing your care with third parties, and consultations with and between other health care providers. This consent includes treatment provided by any physician who covers my/our practice by telephone as the on-call physician. Payment includes activities involved in determining your eligibility for health plan coverage, billing and receiving payment for your health benefit claims, and utilization management activities which may include review of health care services for medical necessity, justification of charges, pre-certification and pre- authorization. Health Care Operations includes the necessary administrative and business functions of our office.

I further authorize Seung H Baek DDS Inc to use and disclose the following specific health and medical information for the below listed purpose(s): Specific medical information consisting of: For the specific purpose of:

If Seung H Baek DDS Inc is requesting this Authorization from you for our own use and disclosure or to allow another health care provider or health plan to disclose information to us: 1) We cannot condition our provision of services or treatment to you on the receipt of this signed authorization; 2) You may inspect a copy of the protected health information to be used or disclosed; 3) You may refuse to sign this Authorization; and 4) We must provide you with a copy of the signed authorization.

You have the right to revoke this Authorization at any time, provided that you do so in writing and except to the extent that we have already used or disclosed the information in reliance on this Authorization. Unless revoked earlier or otherwise indicated, this Authorization will expire 180 days from the date of signing or shall remain in effect for the period reasonably needed to complete the request.

Because we have reserved the right to change our privacy practices in accordance with the law, the terms contained in the Notice may change also. A summary of the Notice will be posted in our office indicating the effective date of the Notice in the upper right hand corner. We will offer you a copy of the Notice on your first visit to us after the effective date of the then current Notice. We will also provide you with a copy of the Notice upon your request.

As more fully explained in the Notice, you have the right to request restrictions on how we use and disclose your protected health information for treatment, payment, and health care operations purposes. We are not required to agree to your request. If we do agree, we are required to comply with your request unless the information is needed to provide you emergency treatment. Other physicians who provide call coverage for our office are required to use and disclose your protected health information consistent with the Notice.

I understand that I have the right to revoke this Consent provided that I do so in writing, except to the extent that Seung H Baek, DDS, Inc. has already used or disclosed the information in reliance on this Consent.