Protected Health Information

THIRD OF THREE FORMS:
Below is the third of three brief forms. Please complete and submit the form to complete the process. We look forward to working with you!

First Name*

Last Name*

Minor Name (if applicable)

Date of Birth

BTI Sports and Wellness, LLC and its affiliated entities (collectively, “Provider”) creates and maintains information about its clients. This information, which is referred to as “protected health information,” is subject to certain privacy protections that are defined in the Provider’s Notice of Privacy Practices (available to you upon request). By signing this authorization form, you are authorizing Provider to use and disclose your or your minor child’s (collectively, “Your” “You” “I” “Me” or “My”) protected health information, as set forth below.

1. I authorize Provider to use and disclose the following protected health information:

My age, My biographical information, My diagnosis, My prognosis, all My dates of service with Provider, the name of all the locations where health care was provided to Me, all My verbal and/or written testimonials and statements, and all My video recordings and photographic images captured, created, maintained, and/or produced by Me or by Provider relating to My experiences with Provider and/or the care I received from Provider.

2. Provider is hereby authorized to disclose My protected health information to the following person(s) and/or entity(ies):

General public at large through all types of internal and external (non-Provider) media, including, without limitation, television, radio, newspaper, internet, publications, websites and social media accounts. SimpL Labs Inc. Any coaches, trainers, therapists, or Physicians listed below:

Labs

3. I authorize Provider to use and disclose My protected health information for the following purpose(s):

Marketing, advertising and promoting Provider’s services and Provider’s employees to the general public at large through all types of internal and external media and research studies.

4. This authorization expires on the following date and/or event:

Exp Date

5. I acknowledge that I have the right to refuse to sign this authorization and Provider may not condition the provision of health care on signing this authorization, except if the sole purpose of the provision of health care is to create protected health information for disclosure to a third party.

6. I acknowledge that protected health information used and disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal and/or state law.

7. I acknowledge that I have the right to revoke this authorization at any time, except to the extent that protected health information has already been used and disclosed by Provider in reliance on this authorization. I understand that I must revoke this authorization in writing by sending a dated and signed letter stating that I revoke this authorization to the Privacy Officer at the following address: BTI Sports and Wellness, LLC, 4772 Essex Drive, Doylestown, PA 18902. I acknowledge that the revocation of the authorization will be effective upon receipt of the revocation letter by the Privacy Officer.

By my signature below, I hereby acknowledge that I have read and understand the terms of this authorization, and voluntarily authorize Provider to use and disclose my protected health information set forth above in accordance with this authorization.

Name (Online Signature)*

Date2*

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