HIPAA RELEASE AND TESTIMONIAL CONSENT FORM

Introduction and Purpose.

This HIPAA Release and Testimonial Consent Form (“Form”) is executed in the State of Michigan and is intended to ensure compliance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and applicable Michigan laws. By this Form, the Patient authorizes Transcend Company, Inc. (“Transcend”), as the Authorized Releasee, to obtain, use, and disclose protected health information (“PHI”) as specified herein. The purpose of this Form is to facilitate the use of the Patient’s testimonials on Transcend’s social media platforms and other marketing channels. The Patient understands that the provision of treatment, payment, enrollment, or eligibility for benefits is not conditioned on signing this authorization.

Definition of Confidential Information.

For the purposes of this Form, “Confidential Information” shall mean all data and information related to the Patient’s past, present, or future health condition, including but not limited to medical records, treatment and examination notes, lab reports, and billing information that is designated as PHI under HIPAA, as amended. This includes information transmitted or maintained in any form or medium, whether electronic, paper, or oral.

Confidential Information does not include information that is:

• Publicly known at the time of disclosure or subsequently becomes publicly known through no fault of the Authorized Releasee or Third Party Recipient;
• Rightfully received by the Authorized Releasee or Third Party Recipient from a third party without breach of any obligation of confidentiality;
• Independently developed by the Authorized Releasee or Third Party Recipient without use of or reference to the Patient’s PHI;
• Disclosed by the Patient without restriction on disclosure.

Scope of the Release.

This HIPAA Release and Testimonial Consent Form authorizes Transcend to use and disclose specific parts of the Patient’s PHI as defined under HIPAA and applicable Michigan law, not the entire medical record. The scope of the release. The scope of the release is limited to the minimum necessary information required to achieve the intended purpose, and includes but is not limited to:

• The Patient’s testimonial;
• The Patient’s name and likeness;
• The Patient’s statements about Transcend’s services;
• Prescriptions and medication information related to Patient’s testimonial;
• The Patient’s social media handle or username, if applicable.

The information may be used by Transcend for purposes that include, but are not limited to, promoting Transcend’s services on social media platforms and other marketing channels. All information requested and disclosed under this Form is directly relevant to these purposes. The Authorized Releasee is obligated to use the information only as permitted by this Form, HIPAA, and applicable Michigan law. This Form does not authorize the release of information beyond the scope described herein without the express written consent of the Patient.

Duration of the Release.

This HIPAA Release and Testimonial Consent Form shall remain in effect until such time as the Patient revokes the authorization in writing. The Patient has the right to revoke this authorization at any time by providing written notice to the Authorized Releasee. However, the revocation shall not affect any actions taken by the Authorized Releasee prior to the receipt of the revocation notice.

Notwithstanding the above, this Form shall automatically expire on the date two years from the date of the Patient’s signature unless an earlier date is specified in this Form. Should the Patient wish to extend the duration of this authorization beyond the specified expiration date, a new HIPAA Release Form must be executed.

Rights to Revoke.

The Patient reserves the right to revoke this Form at any time by providing written notice to the Authorized Releasee. Such revocation shall not affect any action taken prior to the receipt of the notice of revocation, including but not limited to the use or disclosure of the testimonial by the Authorized Releasee. The revocation shall become effective upon the Authorized Releasee’s receipt of the written notice, except to the extent that the Authorized Releasee has already acted in reliance on the Form.

To revoke this Form, the Patient must submit a written revocation to the Authorized Releasee clearly stating the desire to revoke the Form. The written revocation can be sent to our physical address at 3200 Cross Creek Pkwy, Auburn Hills, MI 48326, ATTN: Legal or via e-mail to privacy@transcendcompany.com. The revocation must be signed by the Patient or a legally authorized representative if the Patient is unable to sign. Upon receipt, the Authorized Releasee will cease using the Patient’s testimonial for any purpose, except to the extent that the use of the testimonial has already occurred.

Media Release and Use of Image and Likeness.

By signing this HIPAA Release and Testimonial Consent Form, the Patient hereby grants Transcend and its agents, employees, and assigns, the irrevocable and unrestricted right to use and publish the Patient’s testimonial and likeness for the specific purpose of promoting Transcend’s services on social media platforms and other marketing channels in any manner and medium; and to alter the same without restriction. The Patient hereby releases the Authorized Releasee and its legal representatives from all claims and liability relating to said testimonial and likeness. The Patient agrees that Transcend may include the Patient’s name and social media handle or username, if applicable, in the publication of the testimonial, unless the Patient specifically requests otherwise.

This release applies to PHI, photographic, audio, or video recordings collected for marketing purposes by Transcend, specifically for the publication of testimonials on social media platforms, which may be used for commercial purposes. The Patient acknowledges that the Patient may not receive any financial compensation for any of the foregoing and that participation is voluntary. By signing this Form, the Patient relinquishes any right that the Patient may have to examine or approve the final marketing outcome or any publication, including the aforementioned testimonials, that may be produced in conjunction with them. The Patient understands and agrees that this consent for marketing purposes is entirely separate from and not a condition for receiving any healthcare services from Transcend or any affiliated healthcare providers.

Compliance with HIPAA Regulations.

This Form shall be executed in full compliance with HIPAA, as amended, and any applicable state laws of Michigan. The parties acknowledge their responsibility to protect the privacy and security of the Patient’s Confidential Information, including any Photographs or Images, in accordance with these regulations.

Transcend hereby agrees to use and disclose the Patient’s Confidential Information solely for the purpose specified in this Form and to refrain from using or disclosing the Patient’s Confidential Information for any other purpose, unless expressly permitted by the Patient in writing or as required by law.

Transcend agrees to implement appropriate safeguards to prevent unauthorized use or disclosure of the Patient’s Confidential Information, including any Photographs or Images. This includes, but is not limited to, securing electronic and physical records containing Confidential Information, and ensuring that any agents or subcontractors to whom they provide such information agree to the same restrictions and conditions that apply to them with respect to such information.

In the event of any unauthorized use or disclosure of the Patient’s Confidential Information, Transcend shall promptly notify the Patient and take reasonable steps to mitigate the effects of such breach, in compliance with HIPAA and applicable Michigan state law.

Limitations on Use of Information.

Transcend shall use the Patient’s Confidential Information solely for the purpose of publishing testimonials on social media platforms as specified under this Form and for no other purpose without the express written consent of the Patient. Notwithstanding the foregoing, Transcend may disclose the Patient’s Confidential Information to the extent required by law or in response to a valid order of a court or other governmental body, provided that Transcend makes reasonable efforts to notify the Patient of such disclosure in advance, unless prohibited by law.

Transcend is expressly prohibited from using, disclosing, or distributing the Patient’s Confidential Information, including Photographs or Images, in any manner that is not directly related to the publication of testimonials on social media platforms, unless expressly authorized by the Patient in writing.

Transcend agrees to implement reasonable and appropriate safeguards to protect the Patient’s Confidential Information from unauthorized use or disclosure. Furthermore, Transcend shall comply with all applicable federal, state, and local laws and regulations regarding the privacy and security of the Patient’s Confidential Information, including but not limited to HIPAA, as amended.

Governing Law.

This Form shall be governed by and construed in accordance with the laws of the State of Michigan, without giving effect to any choice or conflict of law provisions or rules. Any legal suit, action, or proceeding arising out of or related to this Form or the transactions contemplated hereby shall be instituted exclusively in the federal courts of the United States or the courts of the State of Michigan in each case located in the County of Oakland, and each party irrevocably submits to the exclusive jurisdiction of such courts in any such suit, action, or proceeding.

Signature and Acknowledgment.

This Form shall not be considered valid until it has been signed by the Patient, or a legally authorized representative, if the Patient is not capable of signing. The signature acknowledges that the Patient or their representative has thoroughly reviewed the contents of this Form, understands its purpose, and agrees to its terms concerning the use and disclosure of Confidential Information and Photographs or Images for marketing purposes and the subsequent publication of testimonials on social media platforms by Transcend. The Patient affirms that all information provided in this Form is accurate and complete to the best of their knowledge. The Patient’s name will be used in the final testimonials where the Patient’s information is used.

IN WITNESS WHEREOF, the Parties have executed this HIPAA Release Form as of the date last written below.

	By:	[cPSignerSignature_MU4GD7d]
		(Signature)
	Name:	[role548ebd9a3fe64e609a086ec68edd1cbf_3521347e-4162-4fc6-9633-e2c01df735e7_string_ayzHmyO]
		(Printed Name)
	Date:	[cPSignerDateField_lURLHGc]