PATIENT TESTIMONIAL RELEASE CONSENT
Purpose of Consent: By checking this box, you are consenting to The Carrell Clinic use and disclosure of the information in your testimonial and acknowledgement that the testimonial may be distributed to the public. "Testimonial" may refer to a quotation, transcript of an interview, photographs and/or videotape. I understand that these mediums may be posted on the Internet, and/or used in print and video marketing materials. I relinquish any rights to the videotape, photographs and/or interview transcript and understand that some or all of the materials may be copied and used by media and/or The Carrell Clinic without further permission.
CONSENT TO RELEASE
I hereby authorize The Carrell Clinic to use my testimonial and any information in the testimonial in its public relations efforts. I understand and approve the disclosure by The Carrell Clinic of testimonial information to the media and other individuals and entities that may be involved in the The Carrell Clinic public relations efforts. I further understand that this Consent is completely voluntary and if I choose not to sign this Consent it will not affect my treatment relationship with The Carrell Clinic or my physician.
understand that I am providing the testimonial information to The Carrell Clinic and that my treating physician will not be providing any information to The Carrell Clinic, including private health information (PHI) in my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including but not limited to the Federal Health Insurance Portability and Accountability Act (HIPAA).
I waive the right of prior approval and hereby release The Carrell Clinic from all claims for damages of any kind based on the use of my testimonial or information in the testimonial. I understand that The Carrell Clinic has the right to modify the wording of any testimonial I provide in order to assure that it complies with the requirements of applicable law. This means my testimonial may be reproduced in whole or in part, or it may be paraphrased.
I understand that I have the right to revoke use of my testimonial at any time. It is my understanding that I may revoke my testimonial by providing written notice to The Carrell Clinic. The Carrell Clinic will use best efforts to remove the testimonial within thirty (30) calendar days of receiving my revocation in writing.
Thank you! We appreciate your participation.