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Name of provider seen
Type of procedure/care received
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Please complete the following sentence:
Thanks to my care at OTOR, I can...
Please share additional details about your story here.
I hereby authorize OrthoTennessee Oak Ridge (OTOR) to publish the personal health information/story I provided to be used in print media, on the radio, TV, the OTOR website, blog and on the following social media platforms: Facebook, Twitter, Pinterest and You Tube.
1. Revocation: I understand that I may revoke this authorization at any time by sending a written notice to OTOR. However, the revocation will not have any effect on any uses or disclosures OTOR may have made before the revocation was received.
2. Expiration: I understand success stories posted by OTOR may stay on its website and social media for an indefinite period of time.
3. Redisclosure: I understand that once my protected health information is used and/or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient(s).
4. Refusal to Sign: I understand that I may refuse to sign this authorization and that OTOR will not condition treatment on whether I sign this authorization.
5. Compensation: I understand that I will receive no financial compensation for the use of my image or protected health information as described herein.
6. Copy: I understand I have a right to request a copy of this authorization.
7. Certification: I certify that I am the patient or the patient’s authorized representative.
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