Authorization For Use or Disclosure of Health Information – Marketing
Last modified: June 14, 2023
I hereby authorize Broad Health P.A. and all members of its affiliated covered entity (collectively, “Broad Health”) to use my image, video recording, audio recording, and personal testimony in articles, films, videotapes, books, portfolios, presentations, marketing materials and similar documents for Broad Health’s marketing, promotion and advertising activities. I hereby consent to the storage and sharing of my image, video, and personal testimony for Broad Health’s marketing, promotional, and advertising purposes.
I understand that I have the right to revoke this Marketing Authorization, in writing, at any time by sending such written notification to Broad Health P.A., located at 154 W. 14th St., 6-110, New York, NY 10011. I understand that information used or disclosed pursuant to this Marketing Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by Federal or State law. Broad Health will not condition my treatment on whether I provide authorization for the requested use or disclosure.
I understand that I have the right to: inspect or copy the health information to be used or disclosed as permitted under Federal or State law; refuse to sign this Marketing Authorization; and receive a copy of this Marketing Authorization.
This Marketing Authorization is valid until I am no longer a patient of Broad Health, for five (5) years from the date indicated below, or for the duration permitted under applicable state law, whichever is earlier.
I have read the above information and authorize Broad Health to use or disclose the identified information for the purposes described herein.
I acknowledge that I have read and agree to the terms of Broad Health’s Marketing Authorization.