Purpose of Consent: By signing this form, I voluntarily consent to allow Des Moines Orthopaedic Surgeons Orthopaedic Centers (DMOS) to use, distribute and disclose my individually identifiable health information provided in the testimonial to the public. This includes photographs and recordings single or multiple purposes in any print publication or electronic media (including but not limited to newspapers, television broadcasts, radio broadcasts, educational materials, studies, social media, magazines, brochures and web sites) as approved by DMOS. This includes both publications and electronic materials prepared by DMOS, as well as outside news organizations. I understand that I will not own or have inspection rights to review or approve the final product or use. In addition, I realize I will receive no payment in connection with any publication or use of photographs, video or audio recordings or statements. I waive any claims that I, or others, have for such payments.
Acknowledgement of Privacy: I understand that the released information may no longer be protected by federal privacy regulations and could be subject to redisclosure. This form does not authorize mental health, substance abuse or HIV-related information beyond the limits of the consent that are protected by federal law for alcohol/drug abuse records or by state law for mental health records, federal requirements (42 C.F.R. Part 2) and the state requirements or (Iowa Code ch.228) which prohibit further disclosure without the specific written consent of the me, the patient, or as otherwise permitted by such law and/or regulations. DMOS is subject to civil and/or criminal penalties may attach for unauthorized disclosure of alcohol/drug abuse or mental health information.
Right to Revoke: I understand that I have the right to revoke this authorization release at any time by providing written notice of your revocation and submitting it to DMOS Compliance Officer. DMOS will make reasonable attempts to remove testimonials from social media and print media. Please understand that revocation of this release will not affect any action DMOS took in reliance on this Release before receiving your revocation (such as investment in advertising or current campaigns). I also understand that any materials in reliance on this authorization, my revocation will not impact these prior disclosures.
Consent to Release Information: I hereby authorize DMOS to use my testimonial and any information contained herein in its public relations efforts. I understand and approve the disclosure of my testimonial information to the media and other individuals and entities that may be involved in the public relations efforts of DMOS Orthopaedic Centers. I understand and acknowledge that the media may be interested in telling my story, and I am willing to cooperate and participate in media interviews as they arise.
Components of Testimonial: I understand that I am providing the testimonial information to DMOS. My treating healthcare provider will not provide any protected information to the media or the public, including private health information in my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including the Health Insurance Portability and Accountability Act (HIPAA).
Right of Prior Approval: I waive the right of prior approval and hereby release DMOS from any and all claims for damages of any kind based on the use of my testimonial or information in the testimonial. By signing below I agree and acknowledge that I have read and understood the above release and agree to all terms described. I am of legal age and freely sign this Consent to Release my Patient Testimonial.
Understanding: This form has been explained to me, or I have read and fully understand this document. I had the opportunity to ask questions and these have been answered to my satisfaction. I understand that I have a right to receive a copy of this authorization. A copy will be provided to me if I request one. By completing this form, I acknowledge that I have read the above Patient Testimonial Release Consent Form and authorize my permission by signing below.