Healthcare Regenerative Speaker Packet

HEALTHCARE REGENERATIVE SPEAKER PACKET

Speaker Information

Presentation Details

Proposed presentation date: ,

Patient Case Presentations (If Applicable)

Will presentation include identifiable patient information or images? Yes No

If yes, obtain written authorization from patient or legally authorized representative. Provide patient case identifier (not PHI):

HIPAA & Media Authorization

Speaker acknowledges that the host organization requires a signed HIPAA authorization from any patient whose identifiable information or images are used. By signing below, speaker certifies that any such authorizations have been obtained, are attached, and permit the following uses:

• Use of de-identified or identified patient images in educational materials and recordings;
• Distribution of recorded content to registrants and for continuing medical education purposes;
• Retention of records by host consistent with applicable law.

Media release permissions (check all that apply):
Permission to audio-record presentation
Permission to video-record presentation
Permission to publish slides, images, and recording for educational distribution

Authorization expiration (if limited):

Conflicts of Interest & Financial Disclosures

Please disclose any financial relationships or relevant affiliations with biomedical manufacturers, device companies, pharmaceutical companies, or other entities that could be perceived as a conflict of interest in connection with this presentation.

Yes No

Honorarium, Expenses & Payment

Will the speaker receive an honorarium or stipend? Yes No

Insurance, Liability & Indemnification

Speaker certifies that they maintain professional liability insurance in accordance with applicable law and professional standards. Speaker agrees to indemnify and hold harmless the host organization, its officers, employees, and agents from any claims arising out of speaker's negligent acts, omissions, or breaches of this agreement, except to the extent caused by the host organization's gross negligence or willful misconduct.

Intellectual Property & Materials

Speaker warrants that materials presented do not infringe third-party intellectual property rights and that speaker has the necessary rights and permissions to use third-party materials. Speaker grants the host organization a non-exclusive, royalty-free license to record, reproduce, distribute, and display presentation materials and recordings for educational purposes, subject to any limitations set forth in writing below.

Cancellation, Withdrawal & Amendments

Speaker may withdraw from the program by providing written notice to the host organization. Host organization may cancel or reschedule the event for any reason. Any amendments to this packet must be made in writing and signed by an authorized representative of the host organization and the speaker.

Certifications & Attestation

By signing below, the speaker certifies under penalty of perjury that the information provided in this packet is true and complete to the best of their knowledge; that all required patient authorizations for identifiable patient data have been obtained and are attached; and that the speaker will comply with applicable privacy and professional standards in preparing and delivering the presentation.

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