Authorization and Release of Testimonial Information:
I hereby authorize Surgical Specialists of Louisiana, L.L.C. (hereinafter the “The Practice”) to take, reproduce, use, publish and/or post photographs, videos and audio recordings of me, written testimonials by me, both before and after my surgery, together with my name, brief biographical information, and information regarding my care and treatment by The Practice for educational or promotional purposes (collectively “the “Testimonial”). The Testimonial may be posted on the Practice’s website, in its brochures, Facebook, Instagram and/or any other social media site, and may be used in connection with publicizing and promoting The Practice. These statements may be used in printed publications, multimedia presentations, on websites or in any other distribution media. I agree that I will make no monetary or other claim against The Practice for the use of the Testimonial.
I understand that signing this authorization is voluntary and is being made at my request. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. Information disclosed under this authorization might be redisclosed by the recipient, and this redisclosure may no longer be protected by federal or state law. Except to the extent action has already been taken in reliance on this authorization, I may revoke this authorization at any time by submitting written notice to The Practice. Unless revoked, this Authorization will expire ten years after the date written below.
I further acknowledge that I am not receiving any fee or royalty for the use of said Testimonial and I waive all rights that I may otherwise have to any claims for payment or royalties in connection with said Testimonial.
In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my Testimonial appears. I hereby hold harmless and release The Practice from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of the use of this Testimonial. I have read and understood this authorization.