I authorize Dr. Sheldon Sediman to use and disclose my records and 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 dental 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 dentist who covers my/our practice by telephone as the on-call dentist.
*Payment includes activities involved in determining your eligibility for health plan coverage, billing and receiving payment for your dental 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 understand that I have the right to revoke this Consent provided that I do so in writing, except to the extent that Dr. Sheldon Seidman has already used or disclosed the information in reliance on this Consent.