Tell Us Your Story

We understand that information about you and your health is personal and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your special authorization before we may use or disclose your protected health information to communicate about the services described below. This authorization form helps us make sure that you are properly informed of how this information will be used or disclosed.

I authorize Diversified Radiology to use and/or disclose my Protected Health Information for marketing and communications purposes as described in this authorization form. Specifically, I hereby authorize the use of written or printed materials to include my testimonial, statement or description previously identified along with the use of my name (typically first name and first initial of last name) and other identifying information such as resident city and state, to appear in Diversified Radiology’s printed or electronic materials, including Diversified Radiology’s website, social media pages, print advertisements, television or radio commercials, or films for marketing or public relations purposes.

In granting my authorization herein, I understand the following:

(1) Diversified Radiology has the right, permission, and license to publish, reproduce, distribute, disclose, or otherwise use my Protected Health Information, in whole or in part, as authorized above in such frequency, as Diversified Radiology shall determine in their sole discretion, without further authorization from me. Information disclosed about me used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and will no longer be protected by the Health Insurance Portability and Accountability Act of 1996.
(2) The material may include Protected Health Information, including written, electronic, photo, and video materials.
(3) I understand that my complete anonymity cannot be guaranteed, for example, it is possible that somebody somewhere - perhaps, for example, somebody who looked after me if I was in a hospital or physician office or a relative - may identify me.
(4) Diversified Radiology marketing and public relations materials, websites, and social media pages may be displayed to a broad audience, such as in a Diversified Radiology office, in marketing pieces, or on social media sites, which may be circulated throughout the healthcare community or to the public. The marketing pieces target patients and physicians, but are seen by many non-doctors/patients, including journalists.
(5) Diversified Radiology marketing and public relations materials may also be placed on Diversified Radiology’s website. This site is open to the general public for free.
(6) Although most of these materials are seen by a local audience, the materials may also be used in national marketing campaigns.
(7) No special compensation will be provided to me for use of my image/video/voice and that I may not be informed in advance of the specific use of my health information or image.
(8) I agree that my authorization provided herein is voluntary, Diversified Radiology does not condition treatment on the signing of this form, and I assume complete responsibility for my actions in connection herewith.
I understand that this authorization will automatically expire 5 years from the date in which it was signed.

By signing this authorization form, you authorize the use and/or disclosure of your protected health information as described above. This information may be re-disclosed if the recipient(s) described on this form is not required by law to protect the privacy of the information. You have the right to refuse to sign this authorization. Your healthcare, payment for your healthcare services, and your healthcare benefits will not be affected if you do not sign this form. You have a right to receive a copy of this form after you sign it. You have the right to revoke this authorization at any time, except to the extent the action has already been taken based upon your authorization. To revoke this authorization, please write to:

Diversified Radiology’s
Privacy Officer
1746 Cole Blvd., Suite 150
Lakewood, CO 80401

Checking this box indicates your signature.