I hereby authorize BioMatrix Specialty Pharmacy, LLC, along with its subsidiaries and affiliates (collectively “BioMatrix”), 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 BioMatrix (collectively, My Personal Information”). I hereby grant to BioMatrix 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 BioMatrix, 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 BioMatrix 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 BioMatrix 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.
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 BioMatrix, its affiliates, officers, managers, employees, successors, agents or assigns and release them from any and all liability from damages, arising from or relating to BioMatrix’s use and disclosure of my protected health information, identifying information, and photographs or images as described above. I understand that this authorization is voluntary, and that I may revoke the authorization at any time by presenting my written revocation to BioMatrix. To do so, I must send a written notice to the BioMatrix Privacy Officer at 855 SW 78th Ave. #C200, Plantation, FL 33324. I understand that such revocation will not apply to information that has already been released in response to this authorization.
Unless otherwise revoked, this authorization will expire TWO YEARS from the signed date.
