I hereby authorize Coastal Virginia Surgery Center, its duly authorized employees or agents, to publish the following personal health testimonial or information relating to the diagnosis, treatment, and health care services provided to me and which identifies my name and other personally identifiable information) to be used in print media, on the radio, TV, the CVSC website, blog and social media platforms.
I understand that any personal health information or other information released via the social media platform(s) above may be subject to re-disclosure by such social media platform(s) and may no longer be protected by applicable Federal and State privacy laws.
I understand that I have a right to revoke this authorization by providing written notice to Coastal Virginia Surgery Center. However, this authorization may not be revoked if Coastal Virginia Surgery Center, its employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization. This authorization is valid from the date of my/my representative’s signature until I retract it in writing to Coastal Virginia Surgery Center 580 City Center Blvd. Newport News, VA 23606. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.