Back in Balance Endorsement

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Patient Testimonial Release Authorization Form

Purpose of Authorization: By signing this authorization form, I am providing ChiroWay Centers to distribute and share my patient testimonial that I provided by the method noted below. Sharing my patient testimonial may include posting the information on the company website, posting the testimonial information on ChiroWay’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 my experience at a ChiroWay Center that is being distributed throughout multiple ChiroWay Center’s advertisements and promotions, and I am receiving no financial remuneration from ChiroWay for providing my testimonial and allowing them to use my protected health information provided only by myself 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 ChiroWay Franchise, LLC. 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 ChiroWay Centers will make a best effort to remove my testimonial and protected health information from ChiroWay's website and other social media pages. Components of My Patient Testimonial: I understand that my patient testimonial for ChiroWay will only include my name, location, photograph, and information provided by me to the organization in my testimonial. I hereby consent to and authorize the use and reproduction, in print or electronic format, by ChiroWay Franchise, LLC of all photographs and video footage taken for any publicity purpose, without compensation. All images and video footage are owned by ChiroWay Franchise, LLC. I understand that all other protected health information derived from care at my ChiroWay Center 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 signing below, I agree and acknowledge that I have read and understood all the elements of this authorization for use of my patient testimonial. This authorization will initially expire 12 months after the date of my signature. However, unless I provide a written revocation, ChiroWay Centers may continue to use my testimonial beyond the 12-month period for marketing purposes. I reserve the right to revoke this authorization at any time by submitting a written request to the Privacy Officer at ChiroWay Franchise, LLC. To revoke the authorization for the use of your patient testimonial, please follow these steps: 1) Draft a written statement clearly indicating your desire to revoke the authorization for ChiroWay Centers to use your testimonial. 2) Ensure that your full name, the date of your original testimonial, and contact details are included in the statement. 3) Send your written request to the Privacy Officer at ChiroWay Franchise, LLC. Upon receipt, ChiroWay Centers will cease using your testimonial for marketing purposes and confirm the revocation with you.
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