Thank you for expressing an interest in letting us share your story with other patients and the public. Please take
your time to review this authorization before signing. This authorization will allow us to share your personal
information with other patients, the media, and the public.
By clicking below, I give my permission to
Pain Specialists of America, its affiliates, assigns, contractors,
employees and staff (collectively, PSA) to be photographed, videotaped, recorded, and interviewed by PSA, the
media, or any other person for use and disclosure by PSA for the purposes of education, promotion, advertising,
marketing, publication, and distribution, within and outside PSA, in any and all media including, without
limitation, websites, magazines, news articles, radio, video productions, and social media (e.g., Facebook,
YouTube, etc.).
I acknowledge that this authorization is not a commitment by PSA to use my photo, video, recording or interview
and that PSA reserves the right to not use my information, or to use only part of my information. I hereby release
any right, title, or interest in the photo, video, recording or interview, and to any control over their use or any
proceeds that may arise. I release and forever discharge and agree to hold harmless PSA from any and all liability
arising from the photo, video, recording or interview, or any use or disclosure by PSA of the photo, video,
recording or interview.
I also acknowledge that PSA may conduct a background check on me using publicly available records.
I understand that:
* This authorization is voluntary. My treatment will not be impacted if I sign this authorization or not.
* This authorization will not expire. It will remain valid unless and until I revoke it. Please see our Notice
of Privacy Practices for how to revoke an authorization.
* Any revocation will be effective as soon as PSA receives it, except to the extent PSA has taken action
in reliance on this authorization.
* Once the photo, video, recording or interview is used or disclosed, such information may no longer
be protected by federal and state privacy laws and could be re-disclosed by the person(s) receiving it.
