I hereby authorize LUX Infusion, along with its subsidiaries and affiliates (collectively “LUX Infusion”), 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, age, treatment, duration of treatment, treatment plan, diagnoses, medication, city and state of residence, testimonial, likeness, image, statements made by me, photographic images, video, audio, identifying information, and other information about my or my child’s life and experience as a patient of LUX Infusion (collectively, “My Personal Information”). I hereby grant to LUX Infusion a perpetual, worldwide right and permission to use, reuse, edit, alter, copy, exhibit, publish, create derivative works, display, transmit or distribute My Personal Information, photographs, images, video, or audio for any lawful purpose. 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, social media posts, or video clips. It may also be used for publications produced by or on behalf of LUX Infusion, including but not limited to advertising, promotional and marketing materials (“Materials”). Such Materials may include sales and educational brochures, display boards, sales campaigns, promotional items, company newsletters, social media, and websites. I authorize LUX Infusion to use, reuse, copy, publish, display, exhibit, reproduce, license to third parties, and distribute the materials in any educational or promotional materials or other forms of media, which may include, but are not limited to articles, magazines, advertisements, recruiting brochures, websites or publications, electronic or otherwise, without notifying me. I understand that I will not be compensated in any way for the taking or use of my or my child’s information, testimonial, photographs, films, audio, and/or video. I understand that LUX Infusion 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 redisclosed.
By signing below, I understand and acknowledge that I have read and understand this authorization, and if I have any questions about the disclosure of my Information, I may contact the LUX Infusion Privacy Officer at 877-337-3002 or 855 SW 78th Ave. #C200, Plantation, FL 33324.
WAIVER AND RELEASE FROM LIABILITY
In consideration of the parties’ mutual promises, the sufficiency of which is hereby acknowledged, I waive any and all claims that I, my heirs and assigns may have, now or in the future, against LUX Infusion, its affiliates, officers, managers, employees, successors, agents or assigns and release them from any and all liability from damages, arising from or relating to LUX Infusion’s use and disclosure of my protected health information, identifying information, and photographs or images as described above. This authorization will remain in effect until revoked by me in writing. I understand that this authorization is voluntary and that I may revoke it at any time by submitting written notice to the LUX Infusion Privacy Officer at 855 SW 78th Ave. #C200, Plantation, FL 33324. I understand that such revocation will not apply to any information already used or disclosed, or to materials already created or distributed prior to the date of revocation.
