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Honoring Privacy & Patient Trust

Media Release & HIPAA Authorization

We celebrate healing, empowerment, and community stories. Your privacy, peace of mind, and explicit consent are at the core of everything we do.

100% Voluntary 3-Year Standard Term Revocable at Any Time

What You Need to Know (In Plain English)

This agreement lets The Chiro Co. share inspiring stories, testimonials, photos, or video from our clinic and community events to help other families discover natural health.

Voluntary

Care is never conditioned on signing.

No Clinical Records

Diagnoses & billing are never disclosed.

3-Year Duration

Expires automatically after 3 years.

Easy to Revoke

Email us anytime at info@thechiroco.com.

Agreement Provisions (Sections 1 – 12)
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Formal Legal Document

MEDIA RELEASE & HIPAA AUTHORIZATION

(Patient/Participant Agreement for Marketing & Promotional Use)

This Media Release and HIPAA Authorization Agreement (“Agreement”) is entered into by the undersigned individual or authorized representative (“Participant”) in favor of The Chiro Co. LLC, a Texas limited liability company with its principal place of business at 318 N. Main St., Grapevine, TX 76051 (“The Chiro Co.”).
Subject to Participant’s right to revoke as set forth in Section 12 of this Agreement, Participant grants The Chiro Co. and its authorized agents and vendors the right to record, use, reproduce, edit, adapt, display, perform, publish, and otherwise use Participant’s name, image, likeness, voice, statements, and any materials provided in connection with media activities Participant conducts with The Chiro Co., including but not limited to social media content, testimonials, before-and-after features, patient stories, promotional videos, photography, interviews, reviews, podcasts, webinars, events, and any other activities that the parties may agree to from time to time (collectively, the “Content”). This grant extends to any format or medium now known or later developed, for any lawful marketing or promotional purpose, and applies to all past, present, and future participation unless and until Participant revokes this authorization in accordance with Section 12.
The Chiro Co. is a HIPAA-covered entity and will handle any protected health information (“PHI”) contained in or associated with the Content in accordance with its Notice of Privacy Practices (“NPP”) and applicable federal and state law. A copy of the NPP is available upon request and at www.thecraftchiropractic.com. This Agreement does not supersede or limit Participant’s rights under HIPAA or the NPP.

A. Description of PHI to Be Used or Disclosed.

Participant authorizes The Chiro Co. to use and disclose the following protected health information for the purposes described below: Participant’s name; photographic, audio, and video images; voice; written or verbal statements; and, where voluntarily shared by Participant, general descriptions of health conditions, symptoms, or treatment outcomes (e.g., “I had low back pain and chiropractic care helped me”). The Chiro Co. will not disclose specific clinical diagnoses, treatment records, or billing information without a separate written authorization.

B. Purpose of Use or Disclosure.

The PHI described above will be used for marketing, advertising, and promotional purposes, including but not limited to: social media posts, website content, paid advertising campaigns, testimonials, and community outreach materials.

C. Authorized Recipients.

The PHI described above may be disclosed to: the general public (via social media, website, and advertising platforms including Meta, Google, and similar); marketing vendors and contractors engaged by The Chiro Co.; and digital advertising platforms used to distribute promotional content.

D. Expiration.

This HIPAA authorization shall remain in effect for three (3) years from the date of signing, unless sooner revoked by Participant in writing.

E. Right to Revoke.

Participant has the right to revoke this HIPAA authorization at any time by submitting a written request to The Chiro Co. at info@thechiroco.com or 318 N. Main St., Grapevine, TX 76051. Revocation is effective upon receipt and applies to future uses only. Revocation does not require The Chiro Co. to retract or remove Content already published or distributed in reliance on this authorization prior to receipt of the revocation.

F. Not a Condition of Treatment.

The Chiro Co. will NOT condition treatment, payment, enrollment, or eligibility for benefits on Participant’s decision to sign or not sign this authorization. Signing this Agreement is entirely voluntary.

G. Potential for Re-Disclosure.

Participant understands that once PHI is disclosed to the general public through marketing or promotional materials, The Chiro Co. cannot control subsequent re-disclosure by third parties, and such information may no longer be protected by HIPAA.

Step 1 of 2

Participant & Event Details

Step 2 of 2

Acknowledgements & Digital Signature

Specific HIPAA Marketing Preference:
Draw your signature here with finger or mouse

By drawing your signature above, you affirm that this digital signature is intended to have the same legal force and effect as a handwritten signature.