CONSENT FOR PATIENT TESTIMONIAL AND RELEASE

I, the undersigned, hereby enter into and voluntarily execute this Consent for Patient Testimonial and Release (“Consent”) with Southern Bone and Joint Specialists, P.A. (“SBJ”).  I have been informed and understand that SBJ is obtaining patient testimonials and that my name, likeness, image, voice, appearance, oral and written statements, if any, and/or performance may be recorded and made a part of published patient testimonial materials (the “Testimonial”).

 1.   I hereby grant SBJ, its employees, contractors, agents and representatives the irrevocable right to use my name (or any fictitious name), likeness, image, voice, appearance, oral and/or written statements, and performance as embodied in the Testimonial, or as provided in any medium related to the making of the Testimonial, or as otherwise recorded on or transferred to videotape, film, slides, photographs, audio tapes, DVDs, printed publications, web sites, television or radio broadcasts, social media or any other media or publication now known or later developed.  This grant includes, without limitation, the right to use any of my background or demographic information, including diagnosis and treatment, as SBJ deems appropriate for purposes of the Testimonial.  This grant also includes, without limitation, the right to edit, digitally enhance or alter, mix or duplicate and to use or re-use the Testimonial in whole or part, as SBJ or its representative may determine.  To the extent the Testimonial includes any protected health information (“PHI”), as defined by the Health Insurance Portability and Accountability Act of 1996 (as amended, “HIPAA”), I have executed SBJ’s HIPAA Authorization to further grant SBJ the right to use and disclose such PHI for purposes of creating and publishing the Testimonial.  In the event I choose in the future to revoke such HIPAA Authorization, SBJ will cease using any PHI contained in the Testimonial or related materials; provided, however, I understand any future revocation of the HIPAA Authorization will not affect any rights I have granted to SBJ under this Consent with respect to information that does not constitute PHI.  SBJ may continue using such information, including, without limitation, de-identified statements or non-identifying images, appearances or likeness, for any lawful purpose.  Additionally, I understand that my revocation of the HIPAA Authorization will not affect any right I have granted under this Consent to the extent SBJ has relied upon such grant prior to the revocation. 

 2.   I hereby waive any right to inspect or approve any finished product, including written copy or any other products that may be created in connection therewith.  SBJ shall have complete ownership of the Testimonial in which I appear, including copyright interests. 

 3.  I grant SBJ, its employees, contractors, agents and representatives the right to broadcast, exhibit, publish, market, sell and distribute the Testimonial, either in whole or in parts, for any purposes that SBJ, in its sole discretion, may determine, including without limitation advertising and promotion. 

 4.  I confirm that I have the right, authority and capacity and competence to enter into this Consent, and I hereby give all clearances, copyright and otherwise, for use of my name, likeness, image, voice, appearance, oral and/or written statements and performance embodied in the Testimonial.  I expressly agree to waive, hold harmless, release and indemnify SBJ and its successors, assigns, affiliates, employees, contractors, agents, representatives and licensees from any and all claims including, without limitation, any and all claims for invasion of privacy, infringement of my right of publicity, defamation (including libel and slander) and any other personal and/or other property rights, arising from, relating to or in any way connected with this Consent.  I agree that I shall not now or in the future assert or maintain any such claim against SBJ, its successors, assigns, affiliates, employees, contractors, agents, representatives and licensees.  I hereby confirm that I will not be paid for my participation in the Testimonial and I hereby waive any and all rights to any compensation, royalties, or payment of any kind associated with my participation in the Testimonial and with SBJ’s current or future use of the Testimonial.

If the person signing is under 18, consent should be given by a parent or guardian as follows:

­­­­­­­­­­This authorization for release of protected health information is provided by Southern Bone and Joint Specialists, P.A. (“SBJ”).  For information about how your medical information may be used or disclosed, please see our Patient Notice of Privacy Practices (the “Notice”).  You have the right to review the Notice before you decide to sign this form.  The Notice is subject to change.  You may request a copy of the Notice from the HIPAA Compliance Officer of SBJ.  The Notice is also posted at SBJ offices.

• YOU MAY REFUSE TO SIGN THIS FORM, HOWEVER IT MAY PREVENT US FROM COMPLETING THE TASK(S) YOU HAVE REQUESTED.
• WE WILL NOT CONDITION YOUR TREATMENT ON AN AUTHORIZATION.
• WE WILL PROVIDE YOU WITH A COPY OF THIS AUTHORIZATION FORM UPON REQUEST.

 

THIS AUTHORIZATION IS VOLUNTARY 

TO BE COMPLETED BY PATIENT OR PATIENT REPRESENTATIVE

do hereby authorize SBJ to obtain, use, disclose or receive my individually identifiable health information as described below.  I understand that this authorization is voluntary.  I understand that information released under this authorization may be redisclosed by the recipient of the information and may no longer be protected by state and federal law. 

I authorize SBJ to use and/or disclose my protected health information to film, videotape, photograph and/or interview me (my “Testimonial”).  I authorize SBJ to use, reuse, disclose, reproduce and/or release to SBJ and its employees, agents, and subcontractors, including, without limitation, film crews and media publishers for purposes of preparing my Testimonial.  I further authorize each of the foregoing to disclose to the general public my Testimonial or any portion thereof or information related to my Testimonial (such as my name, likeness, demographic/biographical information, diagnosis and treatment) in printed publications, web sites, television or radio broadcasts, social media, or any other publication for fundraising, promotion, public affairs, advertising or educational activities.

I understand that I may withdraw my authorization by delivering a signed written notice to the SBJ Compliance Officer at any time, except to the extent that action has been taken in reliance on this statement.  I understand that if I do not withdraw authorization that this statement will not expire and that SBJ will continue to have the right to use my Testimonial (or any portion thereof or information related thereto) for the purposes stated in this authorization.  I have carefully read and understand this authorization, and do hereby expressly and voluntarily authorize the use and/or disclosure of my Testimonial (or any portion thereof or information related thereto) as set forth herein.