Patient Authorization & Agreement

Public Relations/Social Media Purposes – HIPAA Authorization

 

I hereby authorize Fertility Specialists Medical Group (FSMG), its subsidiaries, and any related organizations (“Provider”) to use and disclose information about me for the purposes of creating press releases, news stories, photographs or video clips, website and/or publications, as well as stand-alone picture/graphics in which I may appear or be heard, for use in internal Provider publications and/or disclosure to external media outlets, including but not limited to Provider’s social media platforms.

 

Unless otherwise limited above or below, I authorize the following:

 

The information about me may include my: name, diagnoses, treatment modality or plan (retrospective and/or prospective), age, duration of treatment, city and state of residence, photographs, and information about my life and/or how I came to Provider. Unless otherwise limited above or below, the information may also be disclosed to external media in the form of press releases, stories, patient testimonials, photographs or video clips.  It may be used for internal purposes or on Provider’s website or through Provider’s marketing or educational campaigns.  Provider will not receive any direct or indirect payment from or on behalf of any third party in exchange for the release of this information about me.

 

I understand the provision of health care treatment, payment for my health care and my health care benefits are not dependent on this authorization.  I understand I am not required to sign this authorization, however, the information will not be used or disclosed without such authorization. I understand any information used or disclosed pursuant to this authorization may be subject to redisclosure.

 

I understand that I have the right to revoke this authorization in writing, except to the extent information has already been released pursuant to this authorization at the time of revocation.  I can revoke this authorization by sending correspondence to the Provider at the contact information listed below.

 

I hereby release, discharge, and agree to hold Provider harmless from any liability that may arise from the release of information authorized above.

 

This authorization shall expire 15 years from the date of execution.

 

Patient Consent and Release Agreement

I, the undersigned, grant to Fertility Specialist Medical Group (FSMG), and its affiliated entities, licensees, successors and assigns (collectively called the “Licensed Parties”) a worldwide, perpetual right and license to use, reproduce, print, publish, broadcast and rebroadcast, as well as to copyright, my testimonial statement, voice, picture, name and likeness in any and all media and types of advertising and promotion (collectively referred to as “Advertising”) for the Licensed Parties and their products and services.

 

All right, title, and interest in and to my name, testimonial statement, voice, picture, and likeness used in Advertising pursuant to this Consent and Release, including all copyrights therein, will be the sole property of the Licensed Parties, free from any claims whatsoever by me or my representatives.

 

I understand that I will not have any right to compensation in connection with the Licensed Parties’ use of my name, testimonial statement, voice, picture, or likeness. I hereby release the Licensed Parties and their successors and assigns from any and all claims arising out of their use of my name, testimonial statement, voice, picture, and likeness as agreed to in this document, including without limitation any claims based on libel, slander, or the rights of publicity, privacy or personality. I hereby waive any right to review any Advertising and agree that no advertisement or other material need be submitted to me for any further approval.

 

I acknowledge that this permission authorizes the Licensed Parties to post my testimonial statement, voice, picture, name, and likeness on third party social media web sites (including Facebook, Twitter, Instagram, LinkedIn and YouTube), which may require Licensed Parties to grant the owners and users of such sites a broad license to use such materials for any purpose without notice to or approval from me.

 

The statements attributed to me in any testimonial I provide reflect my actual experience with the Licensed Parties and my honest opinions about the Licensed Parties and/or their products and services. I understand that I have the right to revoke this Consent and Release by delivering written revocation to the Licensed Parties at the contact information listed below; provided however that this will not impose any obligation upon the Licensed Parties to recall or destroy any materials already used, published or disclosed.

 

This Consent and Release does not in any way conflict with any existing commitment on my part. I am of the age of 18 or older and have the right to contract in my own name with respect to this Consent and Release. I understand that the provision of health care treatment, payment for my health care, and my health care benefits are not dependent upon this Consent and Release.

 

I understand that this Consent and Release does not obligate the Licensed Parties to make any use of any of the rights granted herein.

 

Provider Contact Information / Licensed Parties’ Contact Information:

Fertility Specialists Medical Group

Address:

8010 Frost Street, Suite P
San Diego, CA 92123

Phone: 858-505-5555
Main Fax: 858-505-5555