Share Your Story

Share your story and help inspire those seeking fertility treatment

Upload Image One
Upload Image Two


Purpose of Authorization

By checking agree to the client/patient testimonial release authorization I am providing CNY Fertility the authorization to distribute and share my client testimonial that I provided. Sharing my client testimonial may include posting the information on the company website, posting the testimonial information on CNY Fertility's social media pages, including my testimonial on printed advertisements, promotions, and distributing to third party publishers. I agree that I am voluntarily sharing my testimonial about services from CNY Fertility, and I am receiving no financial remuneration from CNY Fertility for providing my testimonial and allowing them to use my protected health information for marketing purposes.

Right to Revoke

I understand that I have the right to revoke this authorization at any time by providing a written request to the Privacy Officer at CNY Fertility. I understand that if I choose to revoke this authorization, it will become effective on the day of the revocation of the authorization. Any prior uses and disclosures of my testimonial with my protected health information will not be subject to the revocation of the authorization. I understand that CNY Fertility will make it best effort to remove my testimonial and protected health information from the CNY Fertility's website and other social media pages.

Components of my Testimonial

I understand that the client testimonial for CNY Fertility will only include my name, location, photograph, and information provided to the organization in my testimonial. I understand that all other protected health information that CNY Fertility creates and maintains for purposes of my care will not be used in my testimonial or for marketing purposes without prior authorization per privacy regulations of the state and Health Insurance Portability and Accountability Act (HIPAA).

By checking agree to the client/patient testimonial release authorization I agree and acknowledge that I have read and understood all of the elements of this authorization for use of my client testimonial.