By signing this form, you acknowledge that you must adhere to all laws and regulations
applicable to the mentor program, including but not limited to the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) which requires authorization to use and disclosure protected health
information in connection with the program.
You agree that the International Association for Orthodontics is not liable for treatment results
and outcomes, and you hereby release the IAO, its employees, agents, and representatives from all
claims for damages resulting from your participation in the mentor program. You further agree to
indemnify, defend, and hold the IAO harmless from any and all claims, suits, actions or proceedings of
any kind arising out of, or in connection with your participation in the mentor program, including any
claims relating to advice or guidance given in connection with the program.