Authorization to Use and Disclose Information:
I hereby authorize the Fertility Institute of San Diego (FISD), its subsidiaries, and affiliated organizations (“Provider”) to use and disclose specific information about me for the purposes of creating and distributing press releases, news stories, photographs, video clips, website content, and other publications. This may include use in Provider’s internal publications and disclosure to external media outlets, including social media platforms.
Types of Information Disclosed:
The specific information about me that may be disclosed under this authorization includes, but is not limited to, images of me and my family, age, duration of treatment, city and state of residence, and personal narrative details about my treatment journey with the Provider. I understand that this may include health information protected under the Health Insurance Portability and Accountability Act (HIPAA).
Purpose of Disclosure:
This information is to be used for public relations, educational, and marketing purposes, including but not limited to press releases, social media posts, and Provider’s marketing campaigns. I acknowledge that the Provider will not receive any direct or indirect payment from third parties in exchange for the release of this information.
No Condition of Treatment:
I understand that my decision to grant this authorization is voluntary and that my treatment, payment, health insurance eligibility, or access to health services at the Provider is not conditioned upon my signing of this authorization.
Redisclosure Warning:
I understand that once my information is disclosed to third parties, it may be redisclosed and might not be protected by HIPAA or other privacy laws, potentially allowing further use of my information without my consent.
Revocation:
To revoke this authorization, I must send a written request to the Provider using the contact information listed below. The revocation request must include my full name, the date I signed this authorization, and a clear instruction that I wish to revoke this authorization. I understand that revocation will not affect any actions already taken by the Provider based on this authorization before they received my revocation notice.
Absence of Compensation:
I understand that I will not receive any form of compensation for the use of my information as described herein.
Privacy Notice Acknowledgment:
I have been informed about the Provider’s privacy practices and my rights regarding my personal and health information under HIPAA.
Release from Liability:
I release and hold the Provider harmless from any liability arising from the authorized release of information.
Duration of Authorization:
This authorization is valid for 15 years from the date of signing, unless sooner revoked.
Patient Consent and Release Agreement:
By signing the form , I grant the FISD and its affiliates a worldwide, perpetual right to use my testimonial, voice, image, and likeness in various media and types of advertising for the Provider and their services, without compensation. I relinquish all rights, titles, and interests in such materials and waive any rights to review or approve their use. I release FISD and its affiliates from any claims related to the use of my information, including libel, slander, or infringement of rights of publicity, privacy, or personality. I can revoke this consent following the process outlined above.
This consent does not conflict with any of my existing commitments. I affirm that I am over 18, have the right to enter into this agreement, and my access to healthcare treatment, payment, or benefits is not dependent on this consent.
Provider / Licensed Parties’ Contact Information for Revocation and Inquiries:
Fertility Institute of San Diego
9850 Genesee Ave, La Jolla, CA 92037
https://fertilityinstitutesandiego.com/
info@fertilityintitutesd.com
858-457-2229
