(1) I hereby voluntarily grant Family Network Chiropractic PC of Kingston, NY and its assigns, licensees and affiliates worldwide permission to use my testimonial regarding my care (collectively the “Material”), including my protected health information disclosed by me, as I have provided in written, filmed, videotaped, transcribed, or otherwise recorded statements, in office postings, in marketing materials or advertising, or on the internet. I waive any right to inspect or approve the final product, including written copy, wherein my testimonial appears. I also understand that Family Network Chiropractic PC of Kingston, NY may decide not to use the Material provided by me.
(2) I hereby release Family Network Chiropractic PC of Kingston, NY and its officers, employees, agents and assigns from and waive all claims, damages, losses and liabilities resulting from the use of my testimonial by Family Network Chiropractic PC of Kingston, NY, including without limitation any claims for personal injury, defamation, right of publicity or invasion of privacy. I hereby hold harmless and release Family Network Chiropractic PC of Kingston, NY from all claims, demands, and causes of action which I, my heirs, representative, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
(3) This Agreement shall be deemed to have been made in, and shall be construed pursuant to, the laws of the State of New York, and any disputes shall be venued in Ulster County, New York.
(4) I am at least eighteen years old. If I am signing this on behalf of a minor, I am legally authorized to and agree to the terms of this agreement on behalf of my child or ward.
(5) I expressly acknowledge that this Authorization is voluntary.
(6) This Authorization shall is valid until it is revoked by me in writing. I understand that this Authorization may be revoked by me at any time, provided I notify Family Network Chiropractic PC of Kingston, NY in writing. However, any revocation shall not apply to the extent that Family Network Chiropractic PC of Kingston, NY has taken any action with my testimonial in reliance on this Authorization.
(7) I understand that any protected health information I voluntarily disclose in my testimonial will be re-disclosed by Family Network Chiropractic PC of Kingston, NY as described in this Authorization, and that information will no longer be protected by Family Network Chiropractic PC of Kingston, NY or the HIPAA Privacy Rules.
(8) I hereby provide my electronic signature by clicking the required box on the Patient Testimonial page on the website of Family Network Chiropractic PC of Kingston, NY.
Our Patient Testimonial Privacy Policy Complies With HIPAA
