TERMS OF USE / AUTHORIZATION FOR RELEASE OF PATIENT-IDENTIFYING INFORMATION

I hereby grant to Olmsted Medical Center (OMC), its agents (including the OMC Regional Foundation), and their respective licensees, successors, and assigns (herein collectively called "the licensed parties") the right to edit, publish, and use or disclose the above content, along with any personally identifying/personal health information included, for the marketing purposes of Olmsted Medical Center.

I hereby confirm that I am fully authorized to share this content, and that I'm fully authorized to supply consent for this content to be used at the discretion of the licensed parties, and that no advertisement or other material based on this content need be submitted to me or any other person for any further approval for use. The licensed parties shall be without liability to me for any distortion or other change resulting from the editing, publication, and use or disclosure of this content for marketing purposes.

I understand that Olmsted Medical Center will not condition treatment on whether I accept these terms.

I understand that I may revoke this authorization by sending a written request for revocation to Olmsted Medical Center's Privacy Officer. If I revoke this authorization, Olmsted Medical Center will no longer use or disclose the above content or any included personally identifying/personal health information as described in this authorization, except to the extent it has already relied upon this authorization. I understand that when Olmsted Medical Center discloses information pursuant to this authorization, the information may no longer be protected by federal or state privacy rules and may be subject to re-disclosure by the recipient of the information.

This authorization shall expire one year from the date it was submitted on this Web site.