Share Your Story

Terms & Conditions

PURPOSE OF AUTHORIZATION

I hereby authorize CNY Fertility to distribute and share the client testimonial that I have provided to CNY Fertility. Sharing my client testimonial may include posting the information on the CNY Fertility website, posting the testimonial information on CNY Fertility's social media pages, including my testimonial on printed advertisements and promotions, and distributing to third party publishers. I agree that I am voluntarily sharing my testimonial about my medical health and/or 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 the written revocation is received by CNY Fertility. 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 its best efforts to remove my testimonial and protected health information from the CNY Fertility's website, social media pages, and printed marketing material but understand that it will be impossible to remove printed marketing material from circulation.

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).

I agree and acknowledge that I have read and understood all of the elements of this authorization for use of my client testimonial.