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Thank you for your interest in sharing your exceptional patient story.

If we pursue publication or distribution of your story, we will ask you to sign an Authorization to Use or Disclose Protected Health Information form, which is required to comply with HIPAA guidelines. We will contact you to follow-up and work with you to answer any questions you may have regarding sharing your patient story.

In submitting my patient story to sentara.com, I certify and agree:

1. I am the sole author of this story.
2. The story is about my patient care by a ¸Û°Äͼ¿âcare doctor or provider. The story does not involve care provided to any other person or by any other healthcare provider.
3. I have taken due care to ensure the story's integrity and, to my knowledge, the story is true and accurate. The story does not contain anything that is unlawful, libelous, or which would, if published, constitute a breach of contract. The story does not infringe on any existing copyright or any other third party rights. Neither my submission of the story nor its publication by ¸Û°Äͼ¿âcare or any of their affiliates or subsidiaries violates or will violate any law, regulation or other legal obligation.
4. The story is original. The story has not been published in any other journal, newspaper or other online publication. The story is not under consideration by any other source.
5. I own all rights, title and interest in the story and all intellectual property rights protecting the story. I hereby give ¸Û°Äͼ¿âcare permission to reproduce and distribute the story to the world, with or without change, in hard copy, digital or any other format, including but not limited to distribution on the Internet, via CD-ROM and inclusion in electronic databases. I have full authority to grant the rights I am granting to ¸Û°Äͼ¿âcare in the story. I retain all other rights in and to the story, including its copyright.
6. ¸Û°Äͼ¿âcare may edit the story prior to publication subject to my approval or choose not to publish it.
7. I hereby release and discharge ¸Û°Äͼ¿âcare from any and all claims and demands arising out of or in connection with the use or publication of the story.
8. Neither I nor any other person or entity will receive any remuneration or consideration, now or in the future for the use or publication of the story by ¸Û°Äͼ¿âcare.
9. I have read this entire Agreement/Release and fully understand its contents. This Agreement/Release shall be binding upon me and my heirs, legal representatives and assigns.