hereby give ASA permission to use my story, patient health information and/or photograph(s) I am submitting for educational and promotional purposes, attached and incorporated into this Agreement as Exhibit A. I understand that ASA may publish this content online and in print materials, and it may be revised and used in part or in its entirety. I authorize the release of my patient health information contained in my submission to ASA and authorize ASA to discuss this information with others.
I also authorize, in addition to the release of the above information, the use of quotes and testimonials, photographs, film, audiotape and/or videotape for the purpose of public relations, business development, sales, and internal and external marketing activities, including use by or for news media, and further authorize the use of my name with said photos, film, print or tape in advertising activities, television commercials or broadcasts, radio ads or broadcasts, onsite vehicles (plasma screens, kiosks, etc.), print ads, annual reports, brochures, web sites, online outlets, outside billboards, business communications, books, scientific or industry papers, internal communications, e-newsletters, email marketing, social media platforms or outlets.
In authorizing the release of the confidential information identified above, I hereby waive all restrictions or privileges imposed by law and release ASA and its staff from any restriction or privilege imposed by law in connection with the disclosure or release of any professional record, observation, or communication. I do understand that the information that is being released may be subject to re-disclosure by ASA and may no longer be protected.