Testimonial HIPAA

I hereby authorize Rapid City Medical Center to use my testimonial and any information in the testimonial in its public relations efforts. I understand and approve the disclosure by Rapid City Medical Center of testimonial information to the media and other individuals and entities that may be involved in the Rapid City Medical Center’s public relations efforts. I acknowledge that the media may be interested in my story, and I am willing to participate in media interviews as they arise.

I understand that I am providing the testimonial information to Rapid City Medical Center and that my treating physician will not be providing any information to Rapid City Medical Center, including private health information in my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including, Health Insurance Portability and Accountability Act (HIPAA).

I waive the right of prior approval and hereby release Rapid City Medical Center from all claims for damages of any kind based on the use of my testimonial or information in the testimonial.

I am of legal age and freely sign this release, which I have read and understood.