Consent for Patient Testimonials

What is the purpose of this consent?

From time to time, Millennium Health asks for patients to share their experiences with our products and services for purposes of including some of that information in our advertising, promotion, training or market research evaluation programs. You have been selected as a possible candidate for providing an actual patient testimonial about your use of Millennium products and services.

What am I authorizing by signing this consent?

By signing this consent, you are giving Millennium Health, LLC and its parents, subsidiaries, successors, agents, business partners, and assigns (“MH”) the right to use, copyright, license, publish, broadcast, display, reproduce, share, disclose, release, and distribute in any manner and in any media medical information, name, personal information, and/or personal experiences that you provide to us in connection with your use of MH products and services (collectively, your “personal information”) on DestionationWell.com and other Millennium health sponsored properties. You are also authorizing MH to alter, adapt, modify, or otherwise use photographs, video or other recordings taken of you alone or in combination with your actual name or a fictitious name, your biographical information, and/or your statements (or summarized versions of your statements) for marketing or advertising purposes, or for informational, training, or educational purposes.

What am I representing to MH by signing this consent?

You are representing that any statements and information that you have provided to MH are accurate, and reflect your true and honest opinion of your experiences.

What can MH do with information, photos, videotapes or other recordings of me and other personal information if I sign this consent?

If you sign this consent, MH may have photos, videotapes or other recordings of you and other personal information published, circulated, or presented in any way and in any media (e.g., DVDs, CDs, printed advertisements, television, internet or radio ads, and/or training programs), MH can disclose, share, and otherwise use your personal information by itself or combine it with other written, printed, graphic, or audio matter, for presentation to the public, health care professionals and other patients and consumers. MH may also edit, reduce, enlarge, or otherwise change images or recordings of you to conform to an advertising, marketing, or training document or piece.

Will MH share information about me with any other parties?

MH may share your personal information with other business partners for purposes related to advertising, promotion, training, or market research programs that relate to MH products, programs, or services. These parties will only be allowed to use your information consistent with this consent, and will not be permitted to use photos, videotapes or other recordings, or other information for their own separate use. The business partners who may receive your personal information include advertising agencies and public relations firms working with MH on our advertising and promotional activities.

Will MH or its business partners contact me?

In some situations, those business partners may contact you to discuss your experience with MH products and services, for the purpose of evaluating appropriate candidates for testimonials or for purposes of preparing a patient testimonial to use with photos, videotapes or other recordings of you or your other personal information.

Am I entitled to any payments or ongoing compensation from the use of my photos, videotapes or other recordings or information?

You will not receive any royalties or other reimbursement for signing this consent or for permitting the use of your testimonial. You also understand that you have no copyright privileges for your personal information provided to MH.

Does this consent expire?

MH will no longer be authorized to disclose your medical information pursuant to this consent after the 20th anniversary of the date that you signed it.

Can I withdraw my consent?

Yes, you can withdraw your consent at any time by sending a written request to withdraw to Millennium Health, LLC . Please allow 30 days from receipt of your request for processing. If you withdraw your consent, it will apply to new uses of photos, videotapes or other recordings of you or personal information about you but will not apply to any use of your photos, videotapes or other recordings of you or personal information that is already initiated, such as advertising or promotional materials that have already been prepared for use. MH does not have an obligation to cease using promotional materials that have already been prepared with your personal information.

What am I releasing by signing this consent?

By signing this consent, you understand that you are releasing MH from any legal claims arising out of the use of your photographs or other personal information by MH, consistent with the allowable uses provided in this consent.

Yes, I understand and agree with the terms and conditions of this consent. I also understand that I am not obligated in any way to sign this consent, and that I am signing it voluntarily. I understand that I will be provided with a copy of this consent upon request.

AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION

I agree to permit Millennium Health, LLC. and its representatives and contractors (together, “MH”) to use and disclose information about me, including my diagnosis and other information related to my use of MH products and services (“Health Information”), for its promotional and marketing activities including video recordings and newsletters. Once this information has been disclosed, federal privacy laws will no longer protect the information from further disclosure. MH, and companies working for MH, may use and disclose my Health Information in the advertising/promotion of any of its services. These advertisements and promotions may be in any media, including video, DVD, CD, internet or paper, and any Health Information about me contained within them, may be viewed by the public at large for so long as the videotapes or other recordings, newsletters, magazines, or books are in circulation or otherwise available. MH will not use or disclose information I disclose during the interview for any other purpose unless: (i) required by law; (ii) needed to make a report to the U.S. Food and Drug Administration about the quality, safety, or effectiveness of an MH product; or (iii) I give written permission for the requested use or disclosure. This promise continues even after this authorization ends or I revoke (take back) this Authorization.

This authorization expires (ends) twenty (20) years after I sign it, which means that MH may continue to disclose my Health Information in its advertisements and promotions for twenty years. I may change my mind and withdraw (take back) this authorization at any time and for any reason. To withdraw this authorization, I agree to notify MH at 16981 Via Tazon, San Diego, CA 92127 in writing that I have changed my mind. However, withdrawing this authorization will not affect any use or disclosure of my Health Information by MH or companies working for MH that occurs before my withdrawal request has been received and processed and does not obligate MH to destroy, recover or cease using any materials already prepared or released for publication.

Instructions: If you agree to permit the use and disclosure of your Health Information for the purposes described above, please sign this Authorization and return it to MH at 16981 Via Tazon, San Diego, CA 92127. You will be given a copy of the Authorization after you have signed it. If you do not wish for your Health Information to be used and disclosed for the purposes described above, you should not sign this authorization.