HCM - PR HIPAA Release Form

Are you a Hanger Clinic patient? *

Yes

Which Hanger Clinic location? (city/state) *

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

Completion of this document authorizes the disclosure and/or use of individually identifiable health information, as provided below, consistent with Federal privacy laws.

Failure to provide all of the information requested may invalidate this Authorization.

Patient Name: *

Date of Birth: (DD/MM/YYY) * +

I authorize the Marketing and Public Relations & Communications Departments of Hanger, Inc. and its affiliated companies ("Hanger") to use, disclose, and publish my image, including a full-faced image of me, voice, likeness, name, other biographical information, and my medical condition and related medical information for Hanger’s internal purposes and/or for the purposes of or relating to marketing, promotions, advertising, media relations and/or public relations activities. I understand this information may be disclosed to the public at large and/or hosted online on social media or video sharing platforms.

This Authorization: (please check the applicable box below)

Is intended to be perpetual unless later revoked as described below; or

Expires as of date or event below

Event or Date HIPAA Authorization Expires:

I understand that I may refuse to sign this Authorization. If I refuse to sign this Authorization, I will be excluded from any and all marketing, promotions, advertising, media relations and/or public relations activities of Hanger. Any compensation provided to me for these purposes must be refunded, in full, to Hanger

Public Relations/Marketing Department| c/o Hanger, Inc. 10910 Domain Drive, Suite 300
Austin, Texas 78758

My revocation will be effective upon receipt, but will not be effective to the extent that Hanger or others have acted in reliance upon this Authorization.

I have a right to receive a copy of this Authorization. I understand that my information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer protected by privacy laws. I understand that Hanger may not condition treatment, payment, enrollment or eligibility for benefits upon execution of this Authorization unless the services are being provided solely for the purpose of disclosing the information to a third party.

Date:
* +

Signature: *

clear

Printed Name: *

If someone other than the patient is signing this Authorization, state your legal authority to act for the patient:

Contact/Phone Number: *