TERMS AND CONDITIONS
Purpose of Authorization
By checking, I agree to the client/patient testimonial release authorization. I am providing CARE Fertility the authorization to distribute and share my client testimonial that I have provided. Sharing my client testimonial may include posting the information on the company website, posting the testimonial information on CARE Fertility's social media pages, including my testimonial on printed advertisements, promotions, and distributing to third party publishers. I agree that I am voluntarily sharing my testimonial about services from CARE Fertility, and I am receiving no financial remuneration from CARE Fertility for providing my testimonial and allowing them to use my protected health information for marketing purposes.
Right to Revoke
I understand that I have the right to revoke this authorization at any time by providing a written request to CARE Fertility. I understand that if I choose to revoke this authorization, it will become effective on the day of the revocation of the authorization. Any prior uses and disclosures of my testimonial with my protected health information will not be subject to the revocation of the authorization, unless it is technically feasible to accomplish. I understand that CARE Fertility will make its best effort in a reasonable time frame to remove my testimonial and protected health information from CARE Fertility's website and other social media pages. For example, coordinating with a third-party webmaster may take some time. Further, please note that once the information is used for any of the authorized purposes above, that information may no longer be protected by HIPAA.
Components of my Testimonial
I understand that the client testimonial for CARE Fertility will only include my name, location, photograph, and information provided to the organization in my testimonial. I understand that all other protected health information that CARE Fertility creates and maintains for purposes of my care will not be used in my testimonial or for marketing purposes without prior authorization per privacy regulations of the state and Health Insurance Portability and Accountability Act (HIPAA).
To the extent I have any intellectual property rights in the photograph, video or testimonial, I grant a perpetual, fully paid up, non-exclusive license to CARE Fertility to use for the purposes above.
Providing authorization is entirely voluntary and will not affect the commitment to treatment by CARE Fertility.
By checking, I agree to the client/patient testimonial release authorization. I agree and acknowledge that I have read and understood all of the elements of this authorization for use of my client testimonial.