PATIENT REVIEW RELEASE CONSENT
Purpose of Consent: By checking this box, you are consenting to The Kraus Back and Neck Institute use and disclosure of the information in your review and acknowledgement that the review may be distributed to the public. "Review" may refer to a quotation, transcript of an interview, photographs and/or videotape. I understand that these mediums may be posted on the Internet, and/or used in print and video marketing materials. I relinquish any rights to the videotape, photographs and/or interview transcript and understand that some or all of the materials may be copied and used by media and/or The Kraus Back and Neck Institute without further permission.
CONSENT TO RELEASE
I hereby authorize The Kraus Back and Neck Institute to use my review and any information in the review in its public relations efforts. I understand and approve the disclosure by The Kraus Back and Neck Institute of review information to the media and other individuals and entities that may be involved in the The Kraus Back and Neck Institute public relations efforts. I further understand that this Consent is completely voluntary and if I choose not to sign this Consent it will not affect my treatment relationship with The Kraus Back and Neck Institute or my physician.
understand that I am providing the review information to The Kraus Back and Neck Institute and that my treating physician will not be providing any information to The Kraus Back and Neck Institute, including private health information (PHI) in my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including but not limited to the Federal Health Insurance Portability and Accountability Act (HIPAA).
I waive the right of prior approval and hereby release The Kraus Back and Neck Institute from all claims for damages of any kind based on the use of my review or information in the review. I understand that The Kraus Back and Neck Institute has the right to modify the wording of any review I provide in order to assure that it complies with the requirements of applicable law. This means my review may be reproduced in whole or in part, or it may be paraphrased.
I understand that I have the right to revoke use of my review at any time. It is my understanding that I may revoke my review by providing written notice to The Kraus Back and Neck Institute. The Kraus Back and Neck Institute will use best efforts to remove the review within thirty (30) calendar days of receiving my revocation in writing.
Thank you! We appreciate your participation.
