Master Clinician Network, LLC
1333 NE Orenco Station Pkwy #482
Hillsboro, OR 97124
971-330-7140
PATIENT 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. Your clinician or therapist (“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, and health information 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 protected health information 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 protected health information (“PHI”). PHI is protected by the provisions of the Health Insurance Portability and Accountability Act, as amended (“HIPAA”), and its regulations.
PATIENT DECLARATIONS
Consideration: In exchange for good and valuable compensation, the sufficiency of which I hereby acknowledge, I agree to the contents of this Patient Authorization and Release without limitation. I understand that no other monies will be paid or will be due under any circumstances.
Protected Health Information Authorization and Release: I acknowledge that my PHI is protected by United States privacy laws, including HIPAA and its regulations. By signing this document, I authorize my Clinician to use and disclose limited health information, including: basic patient information (age, gender, etc.); diagnostic and treatment history related to my speech-language impairment; and any notes or other background information regarding my course of treatment with my Clinician, to the Company. Furthermore, I authorize the Company to use my health information and share my health information with others, and I acknowledge that anyone who receives my health information is not required to keep my health information confidential and is able to share my health information with others without my permission. I understand and agree that my PHI will be presented to Network users during the course of training presentations. My Clinician and the Company may continue to use my health information without any further consent or authorization until I notify both my Clinician and the Company in writing to the addresses listed below in Exhibit A: Addresses for Noticethat I revoke this release of my health information. I understand that any revocation will only end the on-going and future release of my health information. Any disclosures made prior to my revocation will remain authorized.
For more information regarding your privacy rights, you may contact the Office of Civil Rights for the U.S. Department of Health and Human Services (OCR). The OCR’s website is http://www.hhs.gov/ocr/.
Informed Consent:I freely agree that my voice, name, image, likeness, attributes of my personality, and health information 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, I authorize the Company and grant it the unrestrained rights to utilize my voice, name, image, likeness and health information in connection with advertising, publicity, public displays, education, exhibitions, and for sale. I hereby stipulate 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 containing my voice, name, image, and protected health information. I waive any right to inspect or approve the content of any production in which my voice, name, image, likeness, attributes of my personality, and PHI may appear.
General Release: I release, hold harmless, and waive to the fullest extent that I may lawfully do so, any causes of action in law or equity I may have or may acquire against the Company, my Clinician, 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. I expressly stipulate that the Company may utilize my voice, name, image, and protected health information or not as it chooses in its sole discretion without affecting the validity of this document. This document is binding upon my 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:I have read and understand the contents of this document and agree with all of the statements contained herein. I acknowledge and agree that my consent is voluntary and unconditional until such time as I revoke consent.
Signature Page follows
Patient:
Name: Date of Birth:
Address & Contact Information:
Phone:
Email:
Signature: Date:
If patient is under the age of 18, a signature of a custodial parent or legal guardianisrequired:
Parent or Legal Guardian of Patient:
Name:
Address & Contact Information:
Phone:
Email:
Signature: Date:
Exhibit A
Addresses for Notice
Please send any notices regarding revocation of consent to use your PHI to bothaddresses listed below:
To your Clinician:
Fax:
Email:
To the Company:
Master Clinician Network, LLC
1692 NE Orenco Station Pkwy
Hillsboro, OR 97124
Email: admin@masterclinician.org