Share Your Story Waiver

By submitting my personal story or agreeing to be interviewed, I understand that Urology Associates may publish this information to other social media sites, to its website, and to any other company that promotes Urology Associates, including, without limitation, to any news media, all of whom may not be subject to the same federal health privacy laws.

I additionally understand that, once published or released, Urology Associates has no control over who views or uses the information. I further understand that Urology Associates cannot condition treatment or payment on whether I submit this information and that my healthcare or payment for healthcare will not be affected by my refusal. I also understand that submitting my story does not entitle me to any monetary or other compensation.

By submitting this entry, this authorization shall remain in effect for 5 years, and I understand that I can revoke the use of this information at any time by submitting a written revocation to Urology Associates, which will be effective upon receipt by Urology Associates.