Master Clinician Network, LLC
1333 Orenco Station Pkwy #482
Hillsboro, OR 97124
971-330-7140
CLINICIAN AUTHORIZATION AND RELEASE
Master Clinician Network, LLC (the “Company”) offers training opportunities for students and clinicians in its Master Clinician Network (the “Network”), a web-based training portal. Speech-language pathology students are required to complete clinical observation hours as part of their certification requirements. You or your clinic (any such entity, a “Clinician”) has agreed to submit recorded clinical sessions for the purpose of adding to the Network’s library of training content. The Company seeks your informed consent, authorization, and release with regard to your voice, name, image, likeness, attributes of your personality for development and use on the Network. Your participation and agreement is voluntary. You are not required to sign this document, and you may refuse to do so. If you do sign this document, you are giving the Company permission to use your images and clinical sessions in still images, video recordings and/or audio recordings. Additionally, you are releasing the Company from any liability regarding the use and disclosure of your image, likeness, and treatment methodologies. You also agree to screen and monitor the release of protected health information (“PHI”) in accordance with the standards and expectations of the Health Insurance Portability and Accountability Act, as amended (“HIPAA”), and its regulations.
CLINICIAN DECLARATIONS
Consideration: In exchange for good and valuable compensation, the sufficiency of which is hereby acknowledged, Clinician agrees to the contents of this Clinician Authorization and Release without limitation. It is understood and agreed that no other monies will be paid or will be due under any circumstances.
Protected Health Information: Clinician acknowledges that PHI is protected by United States privacy laws, including HIPAA and its regulations. By signing this document, Clinician agrees to restrict the PHI submitted to Company to that information necessary to provide sufficient context to Network users. For illustrative purposes, clinically relevant PHI may include: basic patient information (age, gender, etc.); diagnostic and treatment history related to the patient’s speech-language impairment; and any notes or other background regarding the patient’s course of treatment. Clinician acknowledges and agrees that PHI will be presented to Network users during the course of training presentations. The parties understand and agree that the patient’s informed consent to the use of PHI is of paramount importance. Clinician agrees to promptly notify the Company upon receipt of a notice from a patient revoking the patient’s consent to use his or her PHI.
Consent to use Recordings: Clinician freely agrees that Clinician’s voice, name, image, likeness, attributes of Clinician’s personality, and Clinician’s clinical techniques may be recorded using various mechanical and electrical means and may be used by the Company, including its agents and assigns or any other person so authorized by the Company, in any manner the Company sees fit and for any purpose whatsoever, without limitation of any kind. Without limiting the generality of the foregoing, Clinician authorizes the Company and grants it the unrestrained rights to utilize Clinician’s voice, name, image, likeness and clinical techniques in connection with advertising, publicity, public displays, education, exhibitions, and for sale. Clinician hereby stipulates that all recordings are the sole property of the Company, to do with as it will. The Company is the sole owner of a perpetual copyright of any materials submitted to Company. Clinician waives any right to inspect or approve the content of any production in which Clinician’s voice, name, image, likeness, attributes of Clinician’s personality, and Clinician’s treatment and therapy techniques may appear.
General Release: Clinician releases, holds harmless, and waives to the fullest extent that Clinician may lawfully do so, any causes of action in law or equity Clinician may have or may acquire against the Company, including agents and assigns or any other person so authorized by the Company, for any and all claims, including defamation, libel, slander, invasion of privacy, copyright or trademark violation, right of publicity, or false light arising out of or in connection with the utilization by the Company. Clinician expressly stipulates that the Company may utilize Clinician’s voice, name, image, and clinical techniques or not as it chooses in its sole discretion without affecting the validity of this document. This document is binding upon Clinician’s heirs, successors, representatives, and assigns.
Choice of Law and Venue: This document is governed by the laws of the State of Oregon. All actions must be brought in the courts in and for the State of Oregon.
Acknowledgement:The parties have read and understand the contents of this document and agree with all of the statements contained herein. Clinician acknowledges and agrees that the consents granted herein are voluntary and unconditional.