Leave a Testimonial

HIPAA AUTHORIZATION - USE/DISCLOSURE OF NAME AND PROTECTED HEALTH INFORMATION FOR PROVIDER MARKETING USE

To ensure Provider is acting in accordance with your wishes and using your Testimonial with your authorization, please complete and sign this form. Provider will mail or email you a copy of this signed form and will keep a copy of your signed permission on file.

Provider seeks your consent to reproduce and distribute your Testimonial containing your Protected Health Information for Provider’s marketing purposes, including but not limited to use in Provider’s advertisements and commercials, social media campaigns, medical and general interest publications and medical and patient education information, in all media (including internet/online, TV, radio, newspapers, and magazines) throughout the world (collectively “Provider Marketing Use”).

I understand I am not required to sign this authorization. Provider does not condition treatment, payment, benefit eligibility, or enrollment activities on whether or not I agree to sign this form. I can request that a copy of this authorization be mailed to me. I understand that I will not be entitled to any payment or other form of remuneration as a result of any use of my Testimonial.

I am aware that any Protected Health Information I have disclosed about myself in my Testimonial will exist forever in either a recorded, printed, and/or electronic version or other version as may develop over time, and that once it is published or disclosed in any form it will continue to be used. I understand that information about me used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and will no longer be protected by the federal regulations protecting privacy of an individual’s health information under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable federal and state law.

If I decide to sign this form, I understand I have the right to revoke or withdraw my permission at any time to prohibit future use of my information. To do so, I must send written notice to Provider at Provider’s physical address or to Provider’s email address.

I understand that Provider, as well as other persons or entities, will retain copies of any such electronic or printed versions and may retain these versions forever and that any revocation of this authorization will only extend to the versions of the information within Provider’s control that have not been previously published.

If not revoked/withdrawn by me, this authorization expires ten (10) years from the date that I sign it.

By clicking the check-box below and typing out your name, you agree to the contents within this form.