Client/Patient Testimonial & Model Release Authorization Form

Purpose of Authorization: By signing this authorization form, I am providing Dr Robban Sica LLC Et Al to distribute and share my client testimonial and/or image that I provided.  Sharing my client testimonial may include posting the information on the company website, posting the testimonial information on Dr Robban Sica LLC Et Al’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 Dr Robban Sica LLC Et Al, and I am receiving no financial remuneration from Dr Robban Sica LLC Et Al for providing my testimonial and allowing them to use my protected health information 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 Dr Robban Sica LLC Et Al.  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 Dr Robban Sica LLC Et Al will make it best effort to remove my testimonial and protected health information from the Dr Robban Sica LLC Et Al’s website and other social media pages. 

Components of my Testimonial: I understand that the client testimonial for Dr Robban Sica LLC Et Al will only include my name, location, photograph, and information provided to the organization in my testimonial.  I understand that all other protected health information that Dr Robban Sica LLC Et Al 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). 

By signing below, I agree and acknowledge that I have read and understood all of the elements of this authorization for use of my client testimonial.  This authorization will expire 12 months after the date of the signature.  After the expiration, I understand that Dr Robban Sica LLC Et Al will not be allowed to use my testimonial for any future marketing purposes.  It does not require Dr Robban Sica LLC Et Al to remove my testimonial from the website or other social media pages unless I specifically request a revocation of this authorization.

I prefer to be identified in the following way for my client testimonial:

  • My full first and last name (Sally Sample, City, State)
  • My first name and last initial only (Sally S., City, State)
  • My first and last initial only (S. S., City, State)
  • Please leave my identity anonymous (Anonymous, City, State)
  • Please leave my location off of my client testimonial
  • Other_____________________________

Signature: ______________________________________________ Date: _______________

If not patient, Relationship to Patient: ____________________________________________ Name (Printed):_____________________________________  Date of Birth ______________

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