Patient Testimonial Release Form

Your Clinician, Brea Washington, (hereafter, “Provider”) is requesting your written review of Provider’s services (hereafter, “Testimonial”) for the Provider’s advertising and marketing use for Amethyst Holistic

Health, PLLC.

If you agree to provide a Testimonial, please complete Sections A and B below, as well as the Health Insurance Portability and Accountability Act ("HIPAA") Authorization that follows.

Note: In consideration of your privacy and rights under HIPAA, the Provider cannot use your Testimonial or any other protected health information you disclose on this form unless you complete the HIPAA

Authorization.

Basic Information

First name

Last name

Provider Information

Provider First Name

Provider Last Name

Relationship to the Provider

I have received medication management, psychotherapy/talk therapy, wellness counseling, ADHD/cognitive testing, genetic testing, or other mental health and wellness services from the

Provider.

Acknowledgement of the Business Relationship

I am a client of the Provider and will provide my review based on services I have received at the Provider’s established rate. I will refrain from commenting on services I have received on a complimentary or discounted basis unless I have received those services through Medicaid, Medicare, or another government sponsored health program.

“Client” is defined as an established patient of the Provider at Amethyst Holistic Health, PLLC. In order to write a Testimonial as a client, you certify you have obtained services from the Provider at least once. If your relationship to the Provider does not meet this definition, please do not complete this form.

Name Disclosure Preference

Single choice

Undisclosed/Anonymous: I request that NEITHER my name nor my initials be included with my Testimonial on the Provider’s website. Provider may post my Testimonial on Provider’s website and elsewhere for marketing purposes, but may not list my name or initials.

Initials ONLY: I request that ONLY the initials of my first and last name be included with my Testimonial on the Provider’s website. Provider may post my Testimonial on Provider’s website and elsewhere for marketing purposes, but may ONLY list the initials of my first and last name. (For example: Jane Doe's initials would only be listed under their Testimonial as J.D.)

Testimonial

Please write your Testimonial below:

Please try to keep your Testimonial to 50 words or fewer. If your Testimonial is longer, note that the Provider may not be able to publish it in its entirety.

HIPAA AUTHORIZATION - USE/DISCLOSURE OF NAME AND PROTECTED HEALTH INFORMATION FOR PROVIDER MARKETING USE

To ensure the Provider is acting in accordance with your wishes and using your Testimonial with your authorization, please complete and sign this form. Provider will upload a copy of this signed form to your patient portal account to download for your personal record and keep a copy of your signed permission on file.

First & Last Name

Your Patient Portal Email Address:

Provider seeks your consent to reproduce and distribute your Testimonial containing your Protected Health Information for Provider’s marketing purposes, including but not limited to use in Provider’s advertisements and commercials, social media campaigns, medical and general interest publications and medical and patient education information, in all media (including internet/online, TV, radio, newspapers, and magazines) throughout the world (collectively “Provider Marketing Use”).

I give my permission for the Provider and others authorized by the Provider to use, release, reproduce, and distribute any written statements I provided in Section B of this form (my Testimonial). This includes information about my medical condition, diagnoses, medical care, and/or health coverage if I have included such information in my Testimonial.

I specifically authorize the release of information pertaining to alcohol, drug, and/or substance abuse, diagnosis, or treatment. (If applicable, because I have included such information in my Testimonial)

Yes, I agree

Not applicable

I understand I am not required to sign this authorization. Provider does not condition treatment, payment, benefit eligibility, or enrollment activities on whether or not I agree to sign this form. I can request that a

copy of this authorization be mailed to me. I understand that I will not be entitled to any payment or other form of remuneration as a result of any use of my Testimonial.

I am aware that any Protected Health Information I have disclosed about myself in my Testimonial will exist forever in either a recorded, printed, and/or electronic version or other version as may develop over time,

and that once it is published or disclosed in any form it will continue to be used. I understand that information about me used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and will no longer be protected by the federal regulations protecting privacy of an individual’s health information under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable federal and state law.

If I decide to sign this form, I understand I have the right to revoke or withdraw my permission at any time to prohibit future use of my information. To do so, I must send written notice to Provider at Provider’s

business mailing address or to the Provider’s business email address.

I understand that the Provider, as well as other persons or entities, will retain copies of any such electronic or printed versions and may retain these versions forever and that any revocation of this authorization will

only extend to the versions of the information within Provider’s control that have not been previously published.

If not revoked/withdrawn by me, this authorization expires ten (10) years from the date that I sign it.

Electronic Signatures Notice

If you or your legal representative choose to provide an electronic signature on this form, the electronic signature must be sufficient to result in a legally binding contract under applicable State and other law.

Provider will confirm and/or notify you to re-sign this form if your signature does not meet these requirements after signing this form.

Client or Legal Representative/Parent Signature:

Signature field is empty.

First Name

Last Name

If a personal representative signs this form, that representative warrants that they have also completed a HIPAA Personal Representative Form and hereby represents that they have authority to sign this form on the basis of:

Today's Date: