HIPAA AUTHORIZATION FOR USE AND DISCLOSURE IN MEDIA
I hereby authorize BioMatrix Specialty Pharmacy, LLC, along with its subsidiaries and affiliates (collectively, BioMatrix), and its representatives or agents, to use and disclose information about me or my child, including protected health information as defined by federal and state law, for use in publications and to the general public or media. The information may include my or my child’s name, diagnoses, treatment, medication, health information, photographic images, video, and audio. The information may also be disclosed to external media and may be disclosed in the following, but not limited to, forms: press releases, stories, photographs, video clips, publications produced by or on behalf of BioMatrix, advertising, promotional and marketing materials (“Materials”). Such Materials may include sales and educational brochures, magazines, advertisements, display boards, sales campaigns, promotional items, company newsletters, social media, and websites. I authorize BioMatrix to use, reuse, copy, publish, display, exhibit, reproduce, license to third parties, and distribute the Materials without notifying me. I understand that I will not be compensated in any way for the taking or use of my or my childrens’ information, likeness, identity, photographs, films, audio, and/or video. By signing this authorization, I waive any right to compensation, and my and my successors or assigns also release and hold harmless BioMatrix from and against any claim for any injury in connection with the use, copying, distribution, or display of my or my child’s image, voice, likeness, name or any other identifying characteristics. I understand that BioMatrix will not condition treatment on my provision of this authorization. I understand that any information used or disclosed pursuant to this authorization is no longer protected by federal or state law and may be re-disclosed. This authorization will remain in effect for a period of five (5) years from the date of my signature below or the maximum time period allowed under applicable law.
REVOCATION
I understand that signing this form is entirely voluntary and I have the right to revoke this authorization at any time by giving written notice of my revocation to BioMatrix, ATTN: Privacy Officer, 855 SW 78th Ave., Suite C200, Plantation, FL 33324.