HōttoCare Testimonial & HIPAA Authorization

This authorization allows HōttoCare to use and disclose information you voluntarily provide for educational, outreach, advocacy, and promotional purposes.

Signing this authorization is completely voluntary.

Your decision to authorize—or not authorize—your story will not affect your eligibility for services, benefits, care coordination, or participation in any HōttoCare program.

If you provide your consent, you authorize HōttoCare to use and disclose the information you voluntarily submit, which may include:

• Your written story or testimonial
• Quotes from your story or conversations with HōttoCare
• Your first name, last name, initials, or anonymous identifier (based on your selected preference)
• Your city and/or state (if you choose to share it)
• Photographs you submit
• Videos or audio recordings you voluntarily provide or participate in
• Information about your caregiving experience
• Information about your experience with dementia care or related health conditions that you voluntarily choose to share
• Other information you voluntarily include in your testimonial

This information may include Protected Health Information (PHI) as defined under the Health Insurance Portability and Accountability Act (HIPAA).

With your authorization, HōttoCare may use your story to:

• Publish testimonials on the HōttoCare website
• Share educational content with caregivers and families
• Create printed or digital educational materials
• Publish content on social media platforms
• Include testimonials in newsletters and email communications
• Support community outreach and public awareness efforts
• Present educational information at conferences, webinars, and community events
• Respond to media inquiries and share approved success stories
• Promote HōttoCare's programs and services

HōttoCare may edit your submission for grammar, spelling, formatting, clarity, or length while preserving the overall meaning and intent of your story.

When submitting your story, you may choose how you would like to be identified, including:

• Full name
• First name and last initial
• First name only
• Anonymous

HōttoCare will honor the identification preference you select whenever reasonably practicable.

Your participation is entirely voluntary.

You are under no obligation to:

• Share your story
• Provide photographs or videos
• Authorize publication
• Participate in future interviews or testimonials

Choosing not to participate will not impact your relationship with HōttoCare or your access to services.

Unless otherwise agreed to in writing, you understand that you will not receive financial compensation for the use of your testimonial, story, photograph, video, or related materials.

You may revoke this authorization at any time by submitting a written request to HōttoCare.

Revocation will apply only to future uses and disclosures after HōttoCare receives and processes your request.

Your revocation will not affect:

• Information already published or distributed
• Materials already printed or produced
• Content previously shared with media or third parties
• Uses or disclosures made before your revocation was received

Where reasonably practicable, HōttoCare will discontinue future use of your testimonial after receiving your written request.

You understand that information published on the internet, social media platforms, printed materials, or other public communications may be viewed, copied, shared, downloaded, or redistributed by others.

Once information has been publicly disclosed, HōttoCare cannot guarantee that it can be completely removed from public circulation or from copies made by third parties.

By providing your electronic signature and submitting your testimonial, you authorize HōttoCare to use and disclose the Protected Health Information you voluntarily provide as described in this authorization.

You understand that once your information is disclosed pursuant to this authorization, it may no longer be protected by HIPAA if it is received by individuals or organizations not subject to HIPAA.

By checking the authorization box and typing your name into the electronic signature field, you acknowledge and agree that:

• You have read and understand this authorization.
• You are voluntarily authorizing HōttoCare to use and disclose the information you provide.
• Your electronic signature has the same legal effect as a handwritten signature, to the extent permitted by applicable law.
• The information you provide is true and accurate to the best of your knowledge.
• You have the legal authority to authorize the disclosure of the information you submit. If you are signing on behalf of another individual, you represent that you are authorized to do so.