Photograph, Video & Written Testimonial
Consent and Release Form

The purpose of this release is to give your permission to DeFabio Spine & Sports Rehab, LLC (hereinafter referred to as the practice) to use your information (photographic/video/testimonial) for the practice's own advertising, publicity, educational and promotional purposes.

You agree as follows:

• Your Photography / Video / Written Testimonial: This includes all items and/or information you provide to and/or let the practice record (for example, quotes attributable to you, your voice, video footage, photos, etc.).
• You understand and agree that the practice has the unrestricted right to:
  • Reproduce, copy, modify, create derivatives of, or use the photograph/video/testimonial; and
  • Use your name in connection with photographs/video/testimonials as the practice may choose; and
  • Display, distribute, send or broadcast the photograph/video/testimonial by any means or method.

You give the practice your permission to use your photograph/video/testimonial for the purpose of creating, publishing and distributing promotional, educational, advertising and publicity materials. The practice shall be the copyright owner of all published materials and all extensions and renewals of such copyright. You agree that no promotional idea or document containing the use of the published material needs to be submitted to you for approval.

• The terms of this permission shall begin on the date you have signed below.
• You agree to waive all rights and release the practice from, and shall not sue the practice or take any legal action against the practice for, any claim or cause of action, whether now known or unknown, including without limitations, for defamation, invasion of right to privacy, publicity, or personality, commercial misappropriation of name or likeness or any similar matter, or based upon or relating to the use and exploitation of the photograph/video/testimonial.

I authorize the practice to use and disclose my health information for marketing as follows.

• Description of health information that may be used and/or disclosed: I authorize the practice to use and disclose my protected health information; specifically, information about the condition for which the practice treated me and the outcomes of that treatment, and all information described above.
• Authorized recipients of my health information for the practice's own advertising, publicity, educational, and promotional purposes, and the outcomes of that treatment, and all information to any recipients of the practice's advertising, publicity, educational, promotional material.
• I understand that I have the right to revoke this authorization prior to the expiration date shown below. I may revoke this authorization by writing to the practice's privacy officer at the following address.

• I understand that the information disclosed under this authorization may potentially be re-disclosed by the recipients. The federal privacy rules may not protect my health information from re-disclosure by recipients under this authorization.
• I understand that I may decline to sign this authorization. The practice may not refuse to treat me if I do not sign this authorization.
• This authorization shall expire 10 years from the date shown below.

I have read this release, understand it, and am signing it voluntarily. I understand that any consideration received is full and fair for purposes described above for the use of the photograph/video/testimonial. By my signature, I represent that I am at least eighteen years of age and am competent to execute this authorization and agree to permit the disclosures permitted by this authorization.