Patient Feedback - St. Mary's Neurology Center, Inc.

15267 Amberly Road, Tampa, FL 33647

Telephone: (813) 972-5414
Fax: (813) 972-5413

Please complete and sign the "Client/Patient Testimonial Release Authorization Form" at the bottom of this form.

Your Name

City

State

Rate Us How would you rate your experience at our office? (Scale of 1 to 5 Stars, 5 Stars being the most excellent)

1 Star 2 Stars 3 Stars 4 Stars 5 Stars

Please tell us about your experience at our office.

Client/Patient Testimonial Release Authorization Form

Purpose of Authorization: By signing this authorization form, I am providing St. Mary's Neurology Center, Inc., permission 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 St. Mary's Neurology Center, Inc.’s social media pages, and including my testimonial on printed advertisements and promotions. I agree that I am voluntarily sharing my testimonial about services from St. Mary's Neurology Center, Inc., and I am receiving no financial remuneration from St. Mary's Neurology Center, Inc., 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 St. Mary's Neurology Center, Inc. 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 St. Mary's Neurology Center, Inc., will make its best effort to remove my testimonial and protected health information from the St. Mary's Neurology Center, Inc.’s website and other social media pages.

Components of my Testimonial: I understand that the client testimonial for St. Mary's Neurology Center, Inc., will only include my name, location, and information provided to the organization in my testimonial. I understand that all other protected health information that St. Mary's Neurology Center, Inc., 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 signing below, I agree and acknowledge that I have read and understood all of the elements of this authorization for use of my client testimonial.

I understand that St. Mary's Neurology Center, Inc., has the right to remove my testimonial any time without notice if deemed necessary.

I prefer to be identified in the following way for my client testimonial:

My full first and last name

(Sally Sample, City, State)

My first name and last initial only

(Sally S., City, State)

My first initial and last name only

(S. Sample, City, State)

Other

If "Other" selected above, please explain

Signature

Date

Email address

Phone Number

If not patient, Relationship to Patient

Name (Printed)

Date of Birth

Your information will be encrypted.