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​Coral LLC Patient Testimonial Consent Form

We are dedicated to improving patient care and ensuring a great experience through our platform. We would love to hear your feedback and share it with others! To do so, we need your permission to use your testimonial in our marketing materials, while fully complying with the Health Insurance Portability and Accountability Act (HIPAA).

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Your Privacy Matters:

We will only use your testimonial in ways that protect your privacy. You are not required to provide a testimonial, and choosing to provide one will not affect your care or treatment in any way.

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Patient Authorization

I, the undersigned, authorize Coral LLC to use my testimonial, which may include my opinions, feedback, and experiences with their platform, for the purposes outlined below. I understand that my testimonial may be used in Coral LLC’s marketing materials, including but not limited to websites, social media, brochures, and presentations.

I understand that by signing this form, I am authorizing the use of my testimonial in a manner that may include the following Identifiable information:

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My first name

My last initial

My Picture

General details about my treatment or experience with Coral LLC

 

I understand that the following information will not be used or disclosed in my testimonial:

- Specific details about my medical diagnosis or treatment

- Any information that could identify me beyond what I have permitted above

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Purpose of Use

I authorize Coral LLC to use my testimonial to:

- Show how the Coral LLC platform improves patient care and experiences.

- Market and promote the benefits of Coral LLC’s services to future patients and healthcare providers.

Right to Revoke Authorization

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I understand that I may revoke this authorization at any time by sending written notice to Coral LLC at care@coral.io. However, I understand that any use of my testimonial prior to the receipt of my revocation will not be affected.

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Expiration of Authorization

This authorization will remain in effect until:

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I request a revocation, OR

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Specify a date and time for it to be revoked.​

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Voluntary Participation

I understand that my participation in providing a testimonial is completely voluntary. Declining to provide a testimonial will not affect my treatment or services provided by Coral LLC.

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12352 Market Drive, Oklahoma, OK

73114

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