Consent Form - PHP | Premise Health

Consent to Use Testimonial and Success Story

Thank you for sharing your experience with Premise Health.
Please provide your information and consent below so we can share your story with others to inspire them to take positive actions to get, stay and be healthy.

First Name

Middle Initial

Last Name

Email Address

Date of Birth

Phone

Street Address

Street Address Line 2

City

State

Zip Code

Tell us about your experience.

I Authorize:
I have volunteered to provide specific information regarding my personal experiences with Premise Health. By signing below, I authorize Premise Health to disclose my testimonial/member story publicly. The article about my experience may include the following information about me: name, age clinical information, treatment plans, and results (e.g., test results or diagnosis). I understand that Premise Health may share this information publicly to show the effectiveness of the services that Premise Health provides.

I Authorize:
Publicity Waiver and Release Authorization: I grant to Premise Health Holding Corp., its parent, subsidiary, and affiliated companies, agents, licensees, contractors, vendors, and designees, including their successors and assigns (collectively “Premise Health”), the absolute, royalty- free, irrevocable right and permission with respect to any testimonial or statement, including social media postings, photographs, film, video, or other images taken by Premise Health.

Premise Health has my permission to:
(a) Use, re-use, publish, re-publish, copy, display, and create derivative works in whole or part, individually or in conjunction with other photographs, images, recordings, testimonials, in any medium including, but not limited to, social media, print, and Internet and for any purpose, including, without limitation, to advertising and marketing publications, for any business or commercial purpose; and
(b) Use my likeness, image, and/or name and/or employment title in connection with the uses described above if Premise Health so chooses; and
(c) Copyright the same in the name of Premise Health or any other name that Premise Health may choose.

I Authorize:
I understand that I will not receive any compensation for the use of any testimonial or statements (written or oral), photographs, film, video, or other images or sound recordings taken of me by Premise Health or the use of my name and/or employment title. I hereby release Premise Health from any and all claims and demands arising out of or in connection with the use of such photographs, film, video, or other images, sound recordings, statements, or testimonials, including, but not limited to, any claims of defamation, violation of any moral or artist right, invasion of privacy, right of publicity, emotional distress, or any similar right. I hereby waive any and all rights that I may have in and to such photographs, film, video, or other images, sound recordings, written materials, and/or testimonials and assign all such rights I may have to Premise Health and agree that I shall take no action to challenge or object to the validity of Premise Health’s sole and exclusive ownership rights in same.

I Authorize:
Protection of My Health Information: I understand that Premise Health agrees to abide by all applicable laws and regulations governing the privacy and security of my personal health information. To the extent the information is subject to the Health Insurance Portability and Accountability Act and its implementing regulations (“HIPAA”), Premise Health will abide by HIPAA and maintain the privacy and security of my Protected Health Information (“PHI”) in accordance with its Notice of Privacy Practices (“Notice”). This Notice is available to me at the Health Center and on the Premise Health website. I understand that I may also request a copy of this Notice from Premise Health at any time. I understand that any information I provide may be disclosed through electronic means. I also understand that the information disclosed pursuant to this authorization may be subject to re-disclosure by Premise Health and may no longer be protected by federal or state privacy laws.

I Authorize:
Effective Date: This authorization will expire five (5) years from the date of signature. Further, Member understands and agrees that once Member Story is disclosed publicly by Premise Health, Premise Health may continue to disclose publicly unless revoked by Member as provided for below.

Right to Revoke Authorization: I understand that I may revoke this authorization at any time by submitting notice of my revocation in writing to the Health Center. I understand that my revocation of this authorization does not affect any actions taken prior to receipt by Premise Health of my revocation or any actions that are legally permissible without my specific authorization or permission, including uses and disclosures permitted under HIPAA.

Signature and Copy: I have read and understand this form in its entirety and voluntarily authorize the uses and disclosures of the information described above. I acknowledge that the person executing this form is the person providing the testimonial described above. I further acknowledge I am at least 18 years old. I understand that I have the right to receive a copy of this authorization upon request.

First & Last Name

Today's Date