Submit Your Story

PURPOSE OF AUTHORIZATION
I hereby authorize Center for Reproductive Immunology and Infertility to copy, exhibit, publish and distribute my story submission with images for marketing and other lawful purposes, including but not limited to posting my story on the Center for Reproductive Immunology and Infertility website and its social media pages, and in printed advertisements and promotions. I agree that I am voluntarily sharing my story about services from Center for Reproductive Immunology and Infertility and will not make any monetary or other claim against Center for Reproductive Immunology and Infertility for use of my story (including my protected health information contained in the story I’ve provided) 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 office of Center for Reproductive Immunology and Infertility. I understand that if I choose to revoke this authorization, it will become effective on the day the written revocation is received by Center for Reproductive Immunology and Infertility. Any prior uses and disclosures of my story with my protected health information will not be subject to the revocation of the authorization; how-ever, I understand that Center for Reproductive Immunology and Infertility will make its best effort to remove my story and protected health information from the Center for Reproductive Immunology and Infertility website and its social media pages.

COMPONENTS OF MY TESTIMONIAL
I understand that the client story for Center for Reproductive Immunology and Infertility will only include my name, location, photograph, and information provided to the organization in my Story. I understand that all other protected health in-formation that Center for Reproductive Immunology and Infertility creates and maintains for purposes of my care will not be used in my story or for marketing purposes without prior authorization per privacy regulations of the state and Health Insurance Portability and Accountability Act (HIPAA).
I agree and acknowledge that I am the primary subject of the submitted story and that I am the sole owner of any and all copyrights to photographs and images that I submit to Center for Reproductive Immunology and Infertility.
I agree and acknowledge that I have read and understood all of the elements of this authorization for use of my client story