CNS Patient Testimonials Form

CNS Patient Testimonials | CNS Integrated Behavioral Health & Medicine

 

Share Your Experience!

 

Consent to Release

I hereby authorize CNS Integrated Behavioral Health & Medicine (CNS) to use my comments and opinions in its public relations efforts. I understand and approve the disclosure by CNS of my feedback and testimonial information, to the media and other individuals and entities that may be involved in CNS’s public relations efforts.

CNS https://viagrageneriquefr24.com/ will not use your full name in its literature. I understand and approve the disclosure of only my first name and first initial of my last name. For instance, “John S”.

I understand that CNS will not be disclosing 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 CNS from all claims for damages of any kind based on the use of my testimonial or information in the testimonial. I acknowledge I am of legal age and freely sign this release, which I have read and understood.

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