AIRROSTI REHAB CENTERS, LLC
AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
I hereby voluntarily authorize Airrosti Rehab Centers, LLC and its subsidiaries and affiliates
(“Airrosti”) to use and disclose my health information
(such as my name, demographic information, social media addresses, videos, audio recordings,
photographs, and testimonials, statements, and comments about my care and health condition)
(collectively “Information”) as described below.
Description: I authorize the disclosure of my Information in oral, written or electronic form to the public,
including via social media websites (such as Facebook or Twitter, etc.),
and/or other websites including the Airrosti website,
via physical postings of photographs and autographed items on the Airrosti office walls or bulletin boards,
and by Airrosti in general (“Authorized Recipients”).
I authorize Airrosti to obtain my Information from me, its internal records or
from any public sources, websites, social media postings or re-postings.
Purpose: The Information is being released for the purpose of Airrosti marketing its services.
If such Information is de-identified, I authorize Airrosti to re-identify my Information for this purpose.
Expiration: This Authorization will expire on the date when Airrosti is no longer in the business of providing healthcare services.
Acknowledgements: I understand that I may refuse to sign this Authorization,
and that my health care treatment will not be conditioned upon signing this form.
I also understand that my Information is subject to re-disclosure by the Authorized Recipients and that, once released,
the Information may no longer be protected by federal privacy regulations.
I also understand that I may revoke this Authorization at any time by notifying Airrosti in writing, but if I do,
the revocation will not have any effect on any actions Airrosti took before receipt of my revocation of this Authorization.
I acknowledge that I: (i) am 18 years of age or older and have the right to contract in my own name;
(ii) have read and understand the contents of this Authorization;
(iii) agree and consent to this Authorization by electronic means;
and (iv) hereby state that electronic signatures shall have the same force and effect as original signatures with respect
to these terms and all written agreements and understandings entered into between Airrosti and myself.
