Purpose of Authorization: By signing this authorization form, I am providing Babcock Family Chiropractic 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 Babcock Family Chiropractic’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 Babcock Family Chiropractic, and I am receiving no financial remuneration from Babcock Family Chiropractic 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 Babcock Family Chiropractic. 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 Babcock Family Chiropractic will make a best effort to remove my testimonial and protected health information from the Babcock Family Chiropractic’s website and other social media pages.

Components of My Patient Testimonial: I understand that my patient testimonial for Babcock Family Chiropractic 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 Babcock Family Chiropractic, of all photographs and video footage taken for any publicity purpose, without compensation. All images and video footage are owned by Babcock Family Chiropractic. I understand that all other protected health information that Babcock Family Chiropractic creates and maintains 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). I waive any right to royalties or other compensation arising from or related to the use of my testimonial.

By signing below, I agree and acknowledge that I have read and understood all of the elements of this authorization for use of my patient testimonial. After the expiration, I understand that Babcock Family Chiropractic will not be allowed to use my testimonial for any future marketing purposes. I may remove authorization for use of my patient testimonial at any time by providing a written request to the Privacy Officer at Babcock Family Chiropractic.