Authorization for Use or Disclosure of Health Information - Marketing
Version MKT-AUTH-2.0 | Effective October 9, 2026
I hereby authorize my treating medical practice, including Mindbloom Provider Group, P.A., Mindbloom Medical, P.C., Mindbloom Medical NJ, P.C., Mindbloom Medical KS, P.C., and/or Mindbloom Medical Group of California, P.C. (my "Practice"), to disclose, and Mindbloom, Inc. (“Mindbloom”), which provides technology, marketing, and administrative services and does not provide medical care, to use my name, location, image, video recording, audio recording, health information I choose to include in my testimony, and personal testimony in articles, films, videotapes, books, portfolios, presentations, marketing materials and similar documents that may be shared on Mindbloom’s website and mobile app, and/or on third-party websites, platforms, and other media, for Mindbloom’s marketing, promotion and advertising activities. This Marketing Authorization does not cover any other part of my medical record. I hereby consent to the storage and sharing of my image, video, and personal testimony for Mindbloom’s marketing, promotional, and advertising purposes.
I understand that I have the right to revoke this Marketing Authorization, in writing, at any time by emailing privacy@mindbloom.com or by sending such written notification to Mindbloom at 1317 Edgewater Dr. #1583, Orlando, FL 32804, except to the extent Mindbloom has already acted in reliance on it. I understand that information used or disclosed pursuant to this Marketing Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by Federal or State law. However, State law may prohibit the person receiving my health information from making future disclosures of my information unless another authorization for disclosure is obtained from me, or unless such disclosure is specifically required or permitted by law. My Practice will not condition my treatment, and Mindbloom will not condition my access to any program, on whether I provide authorization for the requested use or disclosure.
I understand that I have the right to: inspect or copy the protected health information to be used or disclosed as permitted under Federal or State law; refuse to sign this Marketing Authorization; and receive a copy of this Marketing Authorization. A copy was emailed to me when I opened the testimonial request, and I may request a copy of my signed Marketing Authorization at any time by emailing privacy@mindbloom.com.
This Marketing Authorization is valid for five (5) years from the date I submit this Authorization electronically, as recorded in Mindbloom, Inc.’s systems, or applicable state law, whichever is earlier. If I am a California resident, it expires one (1) year from the date and time I submit it. Before this Marketing Authorization expires, Mindbloom may ask me to renew it. If I do not renew, Mindbloom will stop using my testimonial content on the channels it controls.
I have read the above information and authorize Mindbloom to use or disclose the identified information for the purposes described herein.
By checking the signature box and clicking "Ready to Share Story," you are electronically signing this Marketing Authorization and acknowledge that you have read and agree to its terms. Mindbloom records your name, email, the date and time of submission, and the version of this Marketing Authorization.