I authorize Mayo Clinic to disclose my name and any protected health information (“PHI”) that is contained in my “share my story” submission (“Submission”) in the following manner:

Mayo Clinic may disclose my Submission (and any included PHI) to third parties who are assisting with preparing my Submission for publication;

I grant Mayo Clinic, and its respective licensee, successors and assigns, the perpetual right to use copy publish and distribute my Submission (and any included PHI), as well as my name, for health information, or promotional purposes (or any other purposes Mayo Clinic deems appropriate) in any print, electronic, or other medium, including social media.

I agree that Mayo Clinic has the right to edit, modify and alter my Submission in any manner as it deems appropriate. I agree that no materials need to be submitted to me for approval and that Mayo Clinic shall be without liability to me or others for the authorized use(s) of my Submission or name. I understand that Mayo Clinic shall not be obligated to make any use of the rights set forth herein, and that I will not receive any payment in connection with this Authorization.

I understand that any PHI used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal law. If I am a Mayo Clinic patient, Mayo Clinic will not condition treatment on whether I sign the Authorization.

This Authorization may be revoked at any time except to the extent action has been taken in reliance upon it. Furthermore, I understand that this authorization will remain in effect until specifically revoked by me. Revocation must be made in writing to Mayo Clinic at the following address: Mayo Clinic Center for Social Media - 200 1st Street SW - Rochester, MN 55905

This Authorization shall be binding upon my survivors, heirs, descendants, administrators, executors and all others who have or may have a legal claim or rights by virtue of my agreeing to this Release and License. I also agree that I am 18 years or older.