Healthcare Patient Voices Agreement

HEALTHCARE PATIENT VOICES AGREEMENT

Patient Information

Insurance Information

Medical History (Brief)

Purpose and Scope of Use

The undersigned Patient grants the Healthcare Provider and its affiliates, agents, contractors and assigns (collectively "Provider") the nonexclusive, royalty-free, irrevocable right to record, reproduce, edit, distribute, and otherwise use Patient's spoken statements, voice recordings, video recordings, written quotations, and/or transcripts (collectively "Patient Voices") for the purposes indicated below, subject to the limitations and conditions set forth in this Agreement.

Project / Program Description:

I grant permission for my Patient Voices to be used for the following purposes (check all that apply):

Legal Terms and Acknowledgments

Grant of Rights: Patient grants Provider the right to use, edit, reproduce, publish, sublicense, and distribute Patient Voices in whole or in part, in any medium now known or later developed, throughout the world, for the purposes selected above. Patient understands that Provider may combine Patient Voices with other materials, including images, graphics, music, and text.

HIPAA and Protected Health Information: Patient acknowledges that Patient Voices may contain protected health information. By signing this Agreement, Patient authorizes the disclosure and use of such protected health information for the permitted uses identified herein. Provider will limit disclosures to the minimum necessary for the stated purposes and will implement reasonable safeguards to protect privacy consistent with applicable law.

Compensation: . Any payment, if applicable, will be provided in accordance with Provider policy and noted in writing prior to use.

Term and Expiration: This authorization shall remain in effect until unless earlier revoked in writing as provided below.

Right to Revoke: Patient may revoke this authorization at any time by submitting a written notice to the Provider contact specified below. Revocation will not apply to uses or disclosures already made in reliance on this authorization prior to receipt of the revocation. Revocation should be sent to:

Limitations and Sensitive Information: Patient understands that sensitive personal data (such as mental health, substance use treatment, HIV status, genetic information) may warrant special handling. Provider will notify Patient prior to any planned disclosure of highly sensitive information and obtain specific additional authorization when required by law or policy.

Release and Indemnification: Patient releases Provider from liability for use of Patient Voices consistent with this Agreement and agrees to indemnify Provider for claims arising from Patient's breach of representations herein. This release does not apply to acts of gross negligence or willful misconduct by Provider.

Representations: Patient represents that Patient is at least 18 years of age, or if under 18, that Patient's legal guardian is signing on Patient's behalf. If Patient is a minor or lacks legal capacity, the person signing below certifies authority to execute this Agreement and bind the minor or incapacitated person.

Governing Law: This Agreement shall be governed by the laws of the state in which the Provider maintains its principal place of business, without regard to conflict of laws principles.

Acknowledgment of Privacy Practices

I acknowledge that I have been provided information regarding how my protected health information will be used and disclosed under this authorization. I understand that signing this form is voluntary and that refusal to sign will not affect my ability to receive treatment, payment, or eligibility for benefits, except where those services are conditioned on this authorization.

Additional Administrative Information

Record Retention: Provider will retain copies of Patient Voices and this authorization according to its record retention policy and applicable legal requirements.

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