1. Who this is between
This authorization and release is between the patient named above (or the patient's parent or legal guardian) ("I," "me," "my") and Sterling Ridge Orthopaedics & Sports Medicine, P.A., including its physicians, employees, contractors and marketing agents ("SROSM").
2. What I am authorizing SROSM to use and disclose
I authorize SROSM to photograph, film and record me, and to use and disclose the items I checked above: my image and likeness in photographs and video; my voice in audio and video recordings; my first name and, only if checked, my full name; and, only if checked, a general description of my treatment at SROSM and my own statements about my experience. SROSM will not disclose any other part of my medical record under this authorization. I understand that a photo or video that shows me at SROSM may reveal that I am a patient of SROSM.
3. Who may receive it and for what purpose
SROSM may use these materials, and share them with its website, printing, advertising and social-media vendors, for marketing, advertising, patient education, community outreach and public relations, in the places I checked above, including SROSM's website, SROSM's social-media accounts, printed materials, in-office displays, and, only if checked, news media, podcasts and third-party publications. Once posted publicly, the materials may be viewed, copied and shared by anyone, and SROSM cannot control further use by third parties.
4. Release of name, image and likeness
I grant SROSM an irrevocable (for materials already produced), royalty-free, worldwide license to use, reproduce, edit, crop, adapt, publish and distribute the materials, in any media now known or later developed, for the purposes above. I waive any right to inspect or approve the finished materials or the way they are used. I understand I will not be paid for this, and I release SROSM from any claim arising from the use of the materials as described here, including claims for invasion of privacy, defamation, or violation of any right of publicity. SROSM owns the photographs and recordings it creates.
5. Marketing disclosure
This authorization is for marketing purposes. SROSM will not receive payment from any third party in exchange for using my information, and I will not receive payment.
6. When this authorization ends
This authorization stays in effect until I revoke it in writing. Materials created while it was in effect may continue to be used; SROSM will make reasonable efforts to stop new uses after I revoke, but cannot recall printed materials or content already published, shared or republished by others.
7. My rights
I may revoke this authorization at any time by sending written notice to SROSM Marketing, 6767 Lake Woodlands Dr, Suite F, The Woodlands, TX 77382, or by email to marketing@srosm.com. Revocation does not affect actions SROSM already took in reliance on this authorization. SROSM will not condition my treatment, payment, enrollment or eligibility for benefits on whether I sign this form; my care is the same either way. Information disclosed under this authorization may no longer be protected by federal privacy law (HIPAA) once it is received by someone who is not a health care provider or health plan, and it may be re-disclosed. I am entitled to a copy of this signed form, and I was offered one today.
8. Signature
I have read this form or had it read to me, I have had the chance to ask questions, and I sign it voluntarily. I confirm that I am the patient and at least 18 years old, or that I am the patient's parent or legal guardian with authority to sign for the patient. I agree that typing my name below is my electronic signature, with the same effect as a handwritten signature.
