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Idaho Center for Reproductive Medicine, PC

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

Description of information to be used or disclosed:

Tesxt/Photo

Who is authorized to use or disclose the information:

Idaho Center for Reproductive Medicine, PC (“ICRM” or the “practice”)

Reason the information will be used or disclosed (If the patient initiates the authorization, the statement “at the request of the individual” is sufficient):

To be posted on ICRM’s social media platforms such as Facebook, Instagram, and website.

(If the purpose listed above includes “marketing”, ICRM will not receive payment as a result of using or disclosing this information. This does not include payment for any services provided to you.)

Expiration date or event:

Five years from the date of this authorization

NOTICE TO PATIENT

- You may refuse to sign this authorization
- The patient or the patient’s representative must read and initial the following statements:
1. I understand that I may refuse to sign this form.
2. I understand that I can request a copy of this form after I sign it.
3. I understand that I may revoke this authorization at any time by notifying ICRM in writing at the address below, but if I do, the revocation will not have any effect on actions the practice has already taken in reliance on this authorization.

I authorize ICRM to use or disclose any medical information specified in this authorization. I understand that I shall receive no compensation for this authorization and release and waive any right/title and/or interest of any kind that I may have in the information or images produced.