Share Your Story

PERSONAL CONSENT AND RELEASE
IMPORTANT NOTICE TO SHARE YOUR STORY PARTICIPANTS. Please read this personal consent and release “Consent” carefully before agreeing to its terms and participating in the Share Your Story program “Program”. This is a legal and binding contract between you and Tenex Health Inc. This Consent contains information related to the use and ownership of your story, images, and other information you provide to Tenex Health and your participation in the Program. By selecting the “I Agree” button below and participating in the Program, you acknowledge that you understand and agree to be bound by the terms set forth in this Consent. You may print this Consent by clicking on the link below or may request a written copy from Tenex Health at any time. If you do not agree to the terms of this Consent, you will not be authorized to participate in the Program. By signing this Consent, I grant Tenex Health and its representatives permission to use my story/photo/video for promotional purposes and, if applicable, to disclose my health information.

• I authorize Tenex Health’s publication of my name/photo/likeness/video and all or part of my testimonial/quotes.
• I authorize this use in various Tenex Health-sponsored literature such as, but not limited to, newsletters, brochures, web pages, and videos promoting the company's products and/or services.
• I understand that Tenex Health will not receive any direct payments for the disclosures.
• I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain Tenex Health products, services, other treatment, or otherwise affect my healthcare eligibility.
• This authorization will remain in effect until I revoke it by providing written notice to Tenex Health.
• I understand that if I request it, Tenex Health will provide me a copy of this authorization.
• (Where applicable) As a patient, I understand that this use potentially discloses personal health information, as covered in my testimonial.
• I understand that I may revoke this authorization at any time by providing written notice as set forth in Tenex Health’s Privacy Policy. However, I understand and agree that if I revoke this authorization, Tenex Health is not responsible for notifying those to whom it has disclosed this information.
• I understand that once disclosed, my health information may be subject to redisclosure, at which point it is no longer subject to federal privacy laws.
• I understand that publishing or any usage of my patient story is at the sole discretion of Tenex Health.

I represent and warrant that I am legally entitled to enter into this Consent and that I acknowledge that this Consent constitutes a legal, valid, and binding obligation.

Print consent