Client/Patient Testimonial Release Authorization Form
Purpose of Authorization: By signing this authorization form, I am providing Four Corners OB/GYN to distribute and share my client testimonial that I provided. Sharing my client testimonial may include posting the information on the company website, posting the testimonial information on Four Corners OB/GYN’s social media pages, and including my testimonial on printed advertisements and promotions. I agree that I am voluntarily sharing my testimonial about services from Four Corners OB/GYN and I am receiving no financial remuneration from Four Corners OB/GYN 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 the Privacy Officer at Four Corners OB/GYN 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. I understand that Four Corners OB/GYN will make it best effort to remove my testimonial and protected health information from the Four Corners OB/GYN ‘s website and other social media pages.
Components of my Testimonial: I understand that the client testimonial for Four Corners OB/GYN will only include my first name and last initial, location, and information provided to the organization in my testimonial. I understand that all other protected health information that Four Corners OB/GYN 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).
By checking the box below, I agree and acknowledge that I have read and understood all of the elements of this authorization for use of my client testimonial. This authorization will expire 12 months after the date of the signature. After the expiration, I understand that Four Corners OB/GYN will not be allowed to use my testimonial for any future marketing purposes. It does not require Four Corners OB/GYN to remove my testimonial from the website or other social media pages unless I specifically request a revocation of this authorization.