Marketing Authorization and Release

I understand that my name, likeness, image, and any statements or testimonials I provide to Apple Healthcare Group and/or The Spring at Apple Healthcare (hereinafter referred to as “The Practice”) may be used in connection with publicizing and promoting The Practice’s services. I authorize The Practice to use my name, image, likeness, brief biographical information, and any testimonial I provide. I hereby irrevocably authorize The Practice to copy, exhibit, publish, or distribute my image and/or testimonial for purposes of publicizing its services or for any other lawful purpose. These materials may be used in printed publications, multimedia presentations, on websites, social media, or in any other distribution media.

I agree that I will make no monetary or other claim against The Practice for the use of my name, image, or statements. In addition, I waive any right to inspect or approve the finished product, including any written copy, wherein my information appears. I acknowledge that The Practice may use my information in compliance with applicable laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA), and that my identifiable health information will not be disclosed without my explicit authorization.

Opt-Out Clause:
I understand that I may withdraw my consent at any time by contacting The Practice in writing. Upon receiving my written request, The Practice will remove my name, image, and information from any future marketing materials. I acknowledge, however, that it may not be possible to remove my information from all previously produced materials, such as printed publications or digital content already in circulation.

I have read the authorization and release information and give my consent for the use and disclosure of my information as indicated above.