Advantage Brain & Trauma

Patient Information

1. Authorization to Use and Disclose PHI

I hereby authorize Advantage Brain & Trauma and its authorized representatives to use and/or disclose my protected health information as described below.

2. Information to be Used/Disclosed

I authorize the use and disclosure of the following (check all that apply):

3. Purpose of the Use/Disclosure

The information identified above will be used for marketing, advertising, educational, and promotional purposes. This includes, but is not limited to, Advantage Brain & Trauma's website, social media accounts (Instagram, Facebook, LinkedIn, etc.), printed brochures, and digital advertisements.

4. Who is Authorized to Receive the Information

I understand that once my information is posted online or in public marketing materials, it will be available to the general public and is no longer protected by HIPAA or other privacy laws. Advantage Brain & Trauma cannot control how third parties may use or share this information once it is public.

5. Expiration

This authorization will expire:

6. Right to Revoke

I understand that I have the right to revoke this authorization at any time by providing a written request to Advantage Brain & Trauma. I understand that my revocation will not apply to any materials or posts that have already been published or distributed prior to receiving my written revocation.

7. Voluntary Participation

I understand that signing this form is completely voluntary. Advantage Brain & Trauma will not condition my medical treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization.

8. Compensation

I understand that I will not receive any financial compensation or royalties for the use of my image, voice, or testimonial.