Illinois Bone & Joint Institute, LLC
INDIVIDUAL AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (Authorization) TERMS AND CONDITIONS
Illinois Bone and Joint Institute, LLC ("IBJI") understands that the privacy of personal health information is of utmost importance and we are committed to protecting that information. We appreciate you being willing to share the experiences you, your child or a patient for whom you are the legal representative had at IBJI, but because of our commitment to our patients' privacy, we must obtain written or electronic authorization before we use any of the information you submit to IBJI - MyStory (referred to in this Authorization as "MyStory").
This Authorization provides the confirmation IBJI needs and helps us make sure you understand what information we will use, how we will use it and who will have access to it, and it also allows us to confirm that, if you are not the patient yourself, you are authorized to submit information on behalf of that patient. Please read the information carefully before agreeing to the terms of this Authorization.
The purpose of MyStory and inclusion of your information in MyStory is solely to voluntarily share your experience at IBJI with others. You are not required to provide information to MyStory for any reason. No one will be refused health care and neither the payment for the patient's health care nor the patient's health care benefits will be affected if you do or do not agree to the terms of this Authorization. If you do not accept this Authorization, we will not publish your information in any of MyStory media.
USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION
What Information is Covered?
This Authorization covers only that information that you submit to IBJI through the MyStory form accessible through IBJI. This Authorization does not permit the release or disclosure of any other information in the patient's medical file with IBJI.
Is Information Confirmed? By Whom?
If we select the information you submit to MyStory for posting, IBJI or our agent will contact you by email before posting the information. By providing your email address, you consent to such email contact. The purpose of such contact is to confirm your Authorization and the information that you submitted via the online form. In order to contact you in this manner, your name and email address may be shared with one or more third party providers that we engage to verify information for use as part of MyStory. We will require all such third parties to comply with the terms of this Authorization with respect to use of your information.
What information will be used or disclosed?
The information used and disclosed will be limited to the information you submit to MyStory through the form available on the website. For clarification, that information may include:
The "Experience Information":
- the patient's first and last name;
- the general area where the patient lives, such as the name of the city or town, the state, province or territory and country where the city or town is located;
- the details you provide about the story of the patient's care at IBJI, including any information you provide about the patient's condition/injury, diagnosis, and treatment (including surgery if applicable);
- the name of the patient's IBJI physician(s), therapist(s) and other caregivers; and
- Any photos and/or videos you provide.
Your "Contact Information":
- Your first and last name;
- Your mailing address;
- Your email address; and
- Your telephone number.
How will my information be used?
If we select your information for use in MyStory and your information is verified, the Experience Information you submit to MyStory may be published electronically on the Internet by posting it to the website and/or through IBJI's social media channels. In addition, IBJI may use your Experience Information for (a) IBJI's educational, training and/or promotional purposes; (b) publicity, advertising, publications and/or solicitation of contributions for IBJI; and/or (c) broadcast or other public display purposes, in each case, in any media selected by IBJI.
In addition, your Contact Information may be used by IBJI or our designees to contact you to verify your information, to confirm your Authorization to use you information, to confirm your authority to submit information on behalf of this patient, or to request permission to use the information you submitted in a manner other than specified in this Authorization.
Nothing in this Authorization requires MyStory or IBJI to use any of the information you submit for any purposes. You acknowledge and agree that IBJI or MyStory may decide in their sole discretion not to use the information you submit and that you have no recourse and no claims as a result of IBJI's or MyStory's decision not to use your information.
Who will see my information?
Anyone visiting the website and/or IBJI's social media channels, attending any educational or training sessions in which we use the information, or anyone viewing any other advertising, publication, solicitation materials, broadcasts or displays we produce may see your Experience Information. Because it will be posted on the Internet on this website and in social media channels, the Experience Information is available to, and you should expect it will be viewed by, the general public.
What happens if I submit sensitive information?
We consider certain details about your treatment to be sensitive information (such as any information related to HIV, substance abuse, psychiatric care, sexually transmitted disease; tuberculosis and genetics). PLEASE DO NOT INCLUDE ANY SUCH SENSITIVE INFORMATION IN THE MATERIALS YOU SUBMIT TO IBJI VIA MYSTORY.
If we identify such sensitive information in your submissions and we are considering your submission for use with MyStory, this sensitive information will be deleted from the materials before use, and if we cannot retain the substance of your submission without such information we will not use your submission. Notwithstanding our right to review submissions and remove sensitive information, we are under no obligation and assume no duty to do so and if you submit the sensitive information to MyStory via the questionnaire on the website, IBJI is not responsible if such information is made public.
How long will you use my information?
What about Photographs or Videos?
You are encouraged to provide photos or videos with your submissions. By submitting such photos or videos (the "Images") you consent to IBJI's broadcasting, internet posting, publication, distribution or other use of the Images and your likeness in any medium whatsoever. You acknowledge and agree that the Images may be used as you provide them, or may be edited or incorporated into other images, recordings, videos, or formats and may be used any number of times. You also acknowledge and agree that you will not receive any compensation or other remuneration for the use of the Images as provided for in this Authorization. You specifically release and agree not to sue IBJI or any of its employees, officers, agents or designees, from or for any liability or other obligation arising from the broadcasting, internet posting, publication, distribution or other use of the Images. This consent extends to any use by IBJI or third party acting on behalf of IBJI with IBJI's authorization.
By agreeing to the terms of this Authorization, you consent to the use or disclosure of all information you submit to MyStory, including any of the patient's protected health information, as described in this Authorization. You acknowledge and agree that the information used in MyStory, whether on the website, the social media channels or in other media, is accessible by the general public and once published on these platforms, the information is available to third parties who have no obligations to maintain the confidentiality of this information and such information is no longer protected by federal health information privacy regulations. These third parties who view your information may copy and redistribute the information without our authorization, and IBJI has and assumes no liability for use of the information by third parties.
You have a right to receive a copy of this Authorization after you have agreed to its terms. If you would like a copy of this Authorization, please send your request to: Illinois Bone & Joint Institute, Marketing & PR Department.
You have the right to revoke this Authorization at any time, provided that any revocation is effective only as to future uses of your information. We will remove your information from any IBJI postings that are currently active at the time of your revocation, but we are not responsible for any publication that has already occurred, and except for any IBJI electronic postings, we are not required to remove, replace or redact any publications (for example, if we used your information in a mail-out or in an advertisement, we are not required to retract such publication, but we will agree not to publish such advertisement again in the future). To revoke this Authorization, please write to Illinois Bone & Joint Institute, Marketing & PR Department.
IBJI will only accept this Authorization (a) with respect to your personal information, provided that you are over the age of 18 or (b) with respect to the personal information of a patient other than yourself, with written confirmation that you are the patient's parent, guardian, or other legal representative. We reserve the right to take whatever steps we deem necessary to confirm your legal authorization to provide information about a patient other than yourself.