Authorization for Use and Disclosure of PHI for Marketing and/or Promotional Purposes
I, __________________________________, authorize Pippen Health of Delaware, PA, Pippen Health of California, PC, Pippen Health of Texas, PA, and their employees, agents, affiliates, and authorized representatives (collectively, “Company”) to use and/or disclose my Protected Health Information (“PHI”), as that term is defined in the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), contained in any photographs, videos, medical records, and/or audio recordings for the following purposes:
- Use in internal and external advertising, marketing, public relations or collateral materials, including but not limited to posting on the website, application, and social media sites owned and operated by Found Health, Inc.
- Use in news releases or stories, including television, newspaper, or radio broadcasts.
- Use in internal and external education and/or training programs for the public and/or medical professionals, including but not limited to use on public websites and social media sites.
- I further authorize Company to use and/or disclose the following PHI in conjunction with the use/disclosure of my photographs, videos and/or audio recordings:
- my first and last name
- my age
- my image
- the fact that I am participating in the Company’s weight care program, including the fact that I am receiving medical treatment from Company-affiliated health care provider(s) and the fact that I am taking prescription medication as a part of my treatment;
- my testimonial quote
- except as specifically described as follows (please describe if applicable):______________________________________________________________
I provide my authorization knowing that:
- The PHI that is used or disclosed pursuant to this authorization, including PHI contained in any photographs, videotapes, or interviews, may be subject to re-disclosure by the recipient(s) and may no longer be protected by HIPAA or other state or federal laws.
- Signing this authorization is voluntary. I have the right to refuse to sign this authorization.
- My treatment is not conditioned on my provision of this authorization.
- I understand that I can revoke or cancel this authorization at any time by sending written notice to:
Attn: Privacy Officer
1 Letterman Dr., C3500,
San Francisco CA 94129
Or via email: firstname.lastname@example.org
If I revoke or cancel this authorization, I understand that the revocation will not apply to PHI that has already been used or disclosed in reliance on my authorization. I understand that I am entitled to receive a copy of this Authorization upon request.
I hereby release, discharge and agree to hold Company harmless from any liability that may arise from the release of information authorized above. Unless I revoke this authorization, it will expire 36 months from the date signed below.
Mailing address: _____________________
Rev. September 21, 2022