By my signature below, I authorize the use or disclosure of the following materials for marketing and/or lobbying purposes:

Photographs/Video. I authorize Select Medical to use approved photographs, video or digital images of myself and/or my family for marketing and/or lobbying purposes in such manner as may be deemed necessary. A copy of the photograph(s)/image(s) will be made available upon request.

Testimonials, Letters or Clinical Case Studies. I authorize Select Medical to use testimonials, thank-you letters that my family or I have written, and/or clinical case studies for marketing and/or lobbying purposes in such manner as may be deemed necessary. A copy of the testimonial/thank-you letter/case study is available upon request. All, a portion or none of this information may be used and no guarantee of use is made.

Social Media. I understand that above mentioned materials may be used on social media. This may include, but is not limited to: Facebook, Twitter, Google+ etc. All, a portion or none of this information may be used and no guarantee of use is made.

I understand that if the person or entity that receives the above information is not a health care provider or health plan covered by the federal privacy regulations, the information described above may be disclosed by such person or entity and will likely no longer be protected by the federal privacy guidelines.

I understand that I may revoke this authorization in writing at any time – except to the extent that action has already been taken by Select Medical in reliance on this authorization – by sending a written revocation to: Select Medical; Attn: Privacy Officer; 4714 Gettysburg Road; Mechanicsburg, PA 17055.

I understand that I am not required to sign this authorization/consent form and that Select Medical will not withhold the provision of treatment as a condition of signing this authorization.

This authorization will not expire.