Testimonial Consent

SHREVEPORT DIRECT CARE, LLC
Shreveport Direct Care and Pat Bass III MD Testimonial/Social Media Release Form

IMPORTANT NOTICE TO TESTIMONIAL PARTICIPANTS

Please read this personal consent and release ("Consent") carefully before agreeing to its terms and participating in the "Patient Story" interview ("Interview") and testimonial ("Testimonial"). This is a legal and binding contract between you and Shreveport Direct Care and Pat Bass III MD ("Physician"). This Consent contains information related to the use, disclosure, and ownership of your story, images, and other information you provide to Physician and your participation in the Interview/Testimonial. By participating in the Interview/Testimonial, you acknowledge that you understand and agree to be bound by the terms set forth in this Consent. If you do not agree to the terms of this Consent, you will not be authorized to participate in the Interview/Testimonial.

By signing this Consent, I grant Shreveport Direct Care and Pat Bass III MD and their representatives permission to use my story/photo/video on their public website and for promotional purposes and, if applicable, to disclose my health information.

  1. If provided, I authorize Shreveport Direct Care and Pat Bass III MD publication of my name/my child's name, photo/likeness/video, and all or part of my/his/her testimonial/quotes.

  2. I authorize this use in various Shreveport Direct Care and Pat Bass III MD-sponsored materials such as, but not limited to, newsletters, brochures, web pages, social media websites, and videos promoting the company's products and/or services. I understand that my story/photo/video will also be accessible from and searchable on the Internet.

  3. I authorize Shreveport Direct Care and Pat Bass III MD's release of this information to media representatives for the purpose of promoting their practice services.

  4. I understand that Shreveport Direct Care and Pat Bass III MD will not receive any direct payments for the disclosures.

  5. I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain Shreveport Direct Care and Pat Bass III MD's services, other treatment, or otherwise affect my healthcare eligibility.

  6. This authorization will remain in effect until I revoke it by providing written notice to Shreveport Direct Care and Pat Bass III MD.

  7. I understand that if I request it, Shreveport Direct Care and Pat Bass III MD will provide me a duplicate copy of this authorization. I acknowledge that I can download a copy of this authorization from this form.

  8. (Where applicable) As a patient, I understand that this use potentially discloses personal health information, as covered in my testimonial.

  9. I understand that I may revoke this authorization at any time by providing written notice as set forth in Shreveport Direct Care and Pat Bass III MD's Privacy Policy. However, I understand and agree that if I revoke this authorization, Shreveport Direct Care and Pat Bass III MD are not responsible for notifying those to whom they have disclosed this information, including media representatives or search engines, such as Google or Yahoo!

  10. I acknowledge that I have been provided a copy of Shreveport Direct Care and Pat Bass III MD's Privacy Policy and that I may request a copy of the same at any time by contacting Shreveport Direct Care and Pat Bass III MD's office in writing.

  11. I understand that once disclosed, my health information may be subject to re-disclosure, at which point it is no longer subject to federal privacy laws.

By checking "agree", I represent and warrant that I am legally entitled to enter into this Consent and that I acknowledge that this Consent constitutes a legal, valid, and binding obligation.