By providing my signature below, I acknowledge that I have received and understand the Sarah Esmail, D.M.D. Privacy Notice. I hereby authorize use or disclosure of my Personal Health Information (PHI) by Sarah Esmail, D.M.D. as necessary during the course of my treatment as an active patient, to obtain payment for my treatment and for other health care operations. I understand that I may request in writing that you restrict how my PHI is used or disclosed to carry out treatment, payment and/or other health care operations. I understand that I have patient rights under HIPAA laws and that I may contact the Sarah Esmail, D.M.D. Privacy Officer if I have any concerns about the use or disclosure of my PHI. I also understand, due to some HIPAA laws, that Sarah Esmail, D.M.D. is not required to agree to my requested restrictions. I understand that I may revoke or change this consent in writing at any time, but a revocation is not effective if Sarah Esmail, D.M.D. has already relied on my authorization to make a particular use of disclosure.