Mindbloom Client Marketing Authorization
Authorization for Use or Disclosure of Health Information - Marketing
By clicking the authorization form's checkbox, I hereby authorize Mindbloom, Inc. and affiliated medical practices, including Mindbloom Provider Group, P.A., Mindbloom Medical, P.C., and/or Mindbloom Medical Group of California, P.C. (collectively “Mindbloom”) to use my image, video recording, audio recording, and personal testimony in articles, films, videotapes, books, portfolios, presentations, marketing materials and similar documents for Mindbloom’s marketing, promotion and advertising activities. 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 sending such written notification to Mindbloom at 1317 Edgewater Dr #1583, Orlando, FL 32804. 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. Mindbloom will not condition my treatment 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.
This Marketing Authorization is valid for five (5) years from the date indicated below, or applicable state law, whichever is earlier.
By clicking the authorization form's checkbox, I acknowledge I have read the above information and authorize Mindbloom to use or disclose the identified information for the purposes described herein.