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AUTHORIZATION FOR USE/DISCLOSURE OF INFORMATION AND CONSENT/USE OF PHOTOGRAPHS AND AUDIO/VIDEO IMAGES
Purpose of Authorization:

By signing this form, I hereby provide consent to allow FAMILY WELLNESS ACUPUNCTURE INC. to use and disclose my testimonial, audio, photos and/or videos in which I may appear and/or be heard, and I acknowledge that they may be distributed to the public.

Right to Revoke: I understand I have the right to revoke this Release at any time by providing written notice of my revocation and submitting it to the Contact Person listed below. Please understand that revocation of this release will not affect any action FAMILY WELLNESS ACUPUNCTURE INC. took in reliance of this release before receiving my revocation.

AUTHORIZATION TO RELEASE


I hereby authorize FAMILY WELLNESS ACUPUNCTURE INC. and staff to use my testimonial, audio, photos, videos in which I may appear and/or be heard, and any information contained herein in its media/public relations efforts. I understand and approve the disclosure of the testimonial, audio, photo, video to the media and other individuals and entities that may be involved in the media/public relations efforts of FAMILY WELLNESS ACUPUNCTURE INC.

I am aware that my protected health information will exist forever in either a recorded, printed, and/or electronic version or other version as may develop over time and that once it is published or disclosed in any form it will continue to be used. I understand that information about me used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and will no longer be protected by the federal regulations protecting privacy of an individual’s health information under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable federal and state law.

I am aware that I am not required to sign this authorization. FAMILY WELLNESS ACUPUNCTURE INC. does not condition treatment, payment, benefit eligibility, or enrollment activities on the signing of this form. I can request a copy of this authorization be mailed to me. I understand that I will not be entitled to any payment or other form of remuneration as a result of any use of any information and audio/video/photographic material

I am of the age of 18 or older and have the right to contract in my own name with respect to this Release. This Release does not in any way conflict with any existing commitment on my part. I understand that this Release does not obligate the Licensed Parties to make any use of any of the rights granted herein.

I waive the right of prior approval and hereby discharge and hold harmless FAMILY WELLNESS ACUPUNCTURE INC. from any and all claims for damages of any kind based on the use of my testimonial, picture, video in which I may appear and/or be heard, audio or information in the testimonial.

By Checking the mark, I agree and acknowledge that I have read and understood the above Release and agree to all terms described.