Relationship with provider
I have received counseling, physical therapy, occupational therapy or other mental health and wellness services from Provider.
Acknowledgement of Business Relationship
I am a paying client of Provider and will provide my review based on services I have received at 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. If I am not a client of Provider, I have another business relationship with Provider such as a consultee, peer, supervisor, supervisee, employee, etc. and am commenting on services or interactions that I have received.
Name Disclosure Preference
By including my name in my review or testimonial I give Provider permission to post my first name and the first initial of my last name next to my Testimonial on Provider’s website and to use this information elsewhere for marketing purposes.
Health Insurance Portability and Accountability Act ("HIPAA") Authorization
By providing a review or testimonial I give my consent for my provider and others authorized by Provider to reproduce and distribute my Testimonial(s) containing my 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 permission for Provider and others authorized by Provider to use, release, reproduce, and distribute my name or initials and any written statements I provided in my submitted feedback form via TSGCounseling.com (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)
I specifically authorize the release of information pertaining to mental health diagnosis or treatment. (If applicable).
I specifically authorize the release of information pertaining to HIV/AIDS test results. (If applicable).
I understand I am not required to submit feedback, reviews or testimonials and I am not required to provide any private information if I choose to do so. Provider does not condition treatment, payment, benefit eligibility, or enrollment activities on whether or not I provide a testimonial either anonymously or with my name. I can request that a copy of this disclosure 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 name, initials and 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. I understand that I have confirmed receipt of these terms, understanding of them and consent to these terms by checking the terms and conditions awareness box on my feedback submission form. If I decide to confirm acknowledgement and consent to these terms by checking the box, 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 physical address or to Provider’s email address. I understand that 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 submitted my feedback form.