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I, the undersigned, acknowledge and understand that Airrosti Rehab Centers, LLC, together with its affiliates and subsidiaries (collectively, “Airrosti”), is using and/or will use my name, likeness, written testimonial, words, image, voice, appearance and/or performance to promote Airrosti, and that I am being made a part of that promotion. Therefore:
1) I grant to Airrosti and its designees the right to use my name, likeness, written testimonial, words, image, voice, appearance, and/or performance to endorse Airrosti, whether recorded on or transferred to videotape, film, slides, photographs, audio tapes, or other media, now known or later developed. This grant includes, without limitation, the right to edit, mix or duplicate, and to use or re‐use, my name, likeness, written testimonial, words, image, voice, appearance, and/or performance in whole or part, and to broadcast, promote, publicize, exhibit, market, sell and otherwise distribute these, in whole or in parts, alone or with other products, for any commercial or non‐commercial purpose that Airrosti or its designees in their sole discretion may determine.
2) I acknowledge and understand that Airrosti or its designee(s) have complete ownership of the promotional items in which I appear, including copyright interests, and that I have no interest or ownership in any part of the promotion or its copyright.
3) I confirm that I have the right to enter into this Release, that I am not restricted in granting the rights contemplated in this Release by any commitments to or other agreements with other parties, and that Airrosti has no financial commitment or obligations to me as a result of this Release or of my inclusion in the promotional items. The rights granted to Airrosti herein are perpetual and worldwide.
4) In consideration of all the above, I hereby acknowledge receipt of reasonable and fair consideration from Airrosti and that this Release shall be valid for an indefinite period of time unless it is revoked. I understand that to revoke this Release, I must submit written notice to Airrosti via email to privacy@airrosti.com but that such revocation will not affect actions or uses that have already taken place, and the revocation will take effect on the 30th day after Airrosti’s receipt of such revocation notice.
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 Release; (iii) agree and consent to this Release 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.
Click “I Accept” to acknowledge that you have read and understand the terms and stipulations of the Airrosti Marketing Release document, and by clicking "I Accept" hereby give agreement to all terms of the Release.
If you do not agree, close this window and your testimonial and/or photo will not be used.
Airrosti Rehab Centers, LLC and its subsidiaries and affiliates (“Airrosti”)
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Airrosti Rehab Centers, L.L.C. 111 Tower Dr., Suite 1 San Antonio TX 78232 |
Attn: Kim Fairchild, [Privacy Officer] Phone number: (210) 802-4677 Email address: kim.fairchild@airrosti.com |
Pursuant to this authorization form (the “Authorization”), I hereby voluntarily authorize the use or disclosure of my Protected Health Information, PHI, regarding Airrosti’s services for marketing purposes. I understand that my PHI will include my individually identifiable health information, such as my name, patient demographic information, and health information, which includes, but is not limited to, information relating to my healthcare condition, diagnosis, disease, and treatment (“Protected Health Information”). I authorize Airrosti to disclose my Protected Health Information for marketing purposes.
Company Name: Airrosti Rehab Centers, LLC
The Protected Health Information is being released at my request for marketing purposes. I authorize the re-identification of my Protected Health Information for this purpose.
Expiration: This Authorization will expire upon the dissolution of Airrosti.
I understand that I may refuse to sign this Authorization, and that my health care treatment, payment, enrollment or eligibility for benefits will not be conditioned upon signing this form. I also understand that, once released, the Protected Health 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 the receipt of the revocation of this Authorization.
Click “I Accept” to acknowledge that you have read and understand the terms and stipulations of the Authorization for Use or Disclosure of Health Information document, and by clicking "I Accept" hereby give agreement to all terms of the Authorization.
If you do not agree, close this window and your testimonial and/or photo will not be used.