AUTHORIZATION FOR DISCLOSURE and Use Of
My Sign-up Information
To
The Parent Review
For
Purposes of Receiving The Parent Review Newsletter

By click accepting these terms I hereby authorize the disclosure and/or use of my sign-up information as described below.

I AUTHORIZE: Mercy Folsom

TO DISCLOSE TO:  The Parent Review

at the following address:    via www.mercyfolsom.org/Patients_And_Visitors/The_Parent_Review_Signup
and at Parent Review Address:    99 Summer St. Boston, MA 02110

I Authorize disclosure and use of the following information only:
X   My sign-up information

PURPOSE:   The purpose and limitations (if any) of the requested use or disclosure is:
X marketing communications to me
X send newsletters to me

EXPIRATION:  This authorization will automatically expire two (2) years from the date of I sign up for the newsletter.

MY RIGHTS: 

• I may refuse to sign/acknowledge this authorization.  My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits.
• I may revoke this authorization at any time and opt out from receiving the newsletter by following the unsubscribe button provided within the emailed newsletter.  My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this authorization.
• Parent Review, as the recipient of my sign-up information, agrees not to further disclose my sign-up information without my consent.
• Additional requests for my personal information may be made of me by affiliates of The Parent Review offering promotional products or services.  I acknowledge such affiliate websites are not under the control of nor in any way endorsed by Hospital.  I am under no obligation to provide such affiliate websites with any information when requested.  I will carefully read the privacy notices of such third parties before I provide them with my information.

REMUNERATION: I understand that Hospital WILL NOT receive remuneration from any third party, including The Parent Review, for the use and/or disclosure of my sign-up information.

If I have any questions about this Authorization, I may contact Hospital's Privacy Offer, the address for whom is available on the Patient Privacy Notice.

I may print a copy of this authorization by clicking here.