"A Higher Standard of Care"
 

My Valir Success Story

Terms of Agreement
 I authorize members of VALIR HEALTH to place on the VALIR HEALTH website my success story regarding treatment I (or the patient) received at VALIR HEALTH. I understand that there is a possibility that I (or the patient) may be identifiable in these written accounts if I decide to identify myself by name or any other means (or the patient).

I agree to release and hold harmless VALIR HEALTH, its agents, officers, and employees from any liability related to the placing of my success story on the VALIR HEALTH website.

I understand that I may refuse to agree with this authorization, and that my refusal to agree will not affect my/the patient’s ability to obtain treatment. I understand that this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance of this information.

I understand that the information released may be subject to re-disclosure by some recipients and may no longer be protected by federal and state privacy rules related to health information.

Authorization for use in treatment or at patient or family’s request will not expire. Authorization for other uses and disclosures indicated above will expire 5 years from the date of agreement to post, however, I acknowledge VALIR HEALTH is unable to control the continued use of my(or patient) success story by non- VALIR HEALTH personnel after the date of this authorization.

I attest that I am the patient identified in the success story or the legal representative of the patient identified in the success story.

To revoke this authorization, please send a written request with a copy of this form to the address below:
Compliance Officer
Valir Health, 825 N. Broadway Ave, Suite 400, Oklahoma City, OK 73102
If you have any questions please call Valir Health at 405.609.3600 or toll free 888.898.2080
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My Story 


Valir Health  |  405-609-3600  |  888-898-2080 (toll free)  |  700 N.W. 7th Street  |  Oklahoma City, OK 73102

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