By submitting this form, I am providing Chesapeake Potomac Regional Cancer Center (CPRCC) permission to distribute and share my patient testimonial that I provided. Sharing my patient testimonial may include posting the information on the company website, posting the testimonial information on CPRCC'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 CPRCC, and I am receiving no financial remuneration from CPRCC for providing my testimonial and allowing them to use my protected health information for marketing purposes.

I understand that I have the right to revoke this authorization at any time by providing a written request to the Privacy Officer at CPRCC. 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 CPRCC will make its best effort to remove my testimonial and protected health information from the CPRCC's website and other social media pages.

I understand that the patient testimonial for CPRCC will only include my name, location and information provided to the organization in my testimonial. I understand that all other protected health information that CPRCC 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 proceeding with the survey and submitting the form, I agree and acknowledge that I have read and understood all of the elements of this authorization for use of my patient testimonial.