Authorization for Use and Disclosure of Photographs for Marketing Purposes

(HIPAA Authorization — 45 CFR § 164.508)

Patient name:   Date of birth:

Dental practice / provider:

1. What I am authorizing

I authorize the provider named above to use and disclose clinical photographs of my teeth, mouth, and smile taken before, during, and after my dental treatment (the “Photographs”), as described below.

2. Purpose and where the Photographs may appear

• The provider’s professional portfolio and profile pages on the internet (including dentfol.io)
• The practice’s website and social media accounts
• Printed marketing materials displayed in or distributed by the practice

Other (specify):

3. What I understand

• My name and other identifying information will not be published alongside the Photographs unless I separately agree in writing.
• Because the Photographs may appear publicly on the internet, they may be viewed, saved, or re-shared by others, and once published, complete removal from the internet cannot be guaranteed.
• Information disclosed under this authorization may no longer be protected by federal privacy law once it is publicly displayed.
• I will not receive payment or other remuneration in exchange for this authorization, and I am not required to sign it. My treatment, payment, enrollment, or eligibility for benefits does not depend on signing this form.
• I may revoke this authorization at any time by writing to the practice at the address on file. Revocation stops future uses, but does not undo uses or disclosures already made in reliance on this authorization.

4. Expiration

This authorization expires (choose one):  ☐ on this date:   ☐ when I revoke it in writing