AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

I authorize the disclosure of my health information as follows:

1. I authorize Sanvello Behavioral Health Services, PA and any of its affiliated Sanvello behavioral health service providers (“Sanvello”) to disclose pictures, videos, testimonials, and other website content about me and the care I received at Sanvello.
2. I authorize Sanvello to disclose the health information described above to public users and visitors to Sanvello.com, the Sanvello app, and Sanvello social media pages and sites (including without limitation Facebook, Twitter, YouTube).
3. I authorize the disclosure of the health information described above for purposes of providing information and promotional content about Sanvello’s services to users and visitors to Sanvello.com, the Sanvello app, or Sanvello social media pages and sites.
4. I understand that I may revoke this authorization by writing to Sanvello at 150 South Fifth Street, Suite 825, Minneapolis, MN 55402.
5. I understand that information disclosed under this authorization may be redisclosed by the recipients. Federal or state privacy rules may not protect my health information once the recipients redisclose my health information.
6. I understand that I may decline to sign this authorization.
7. This authorization has no expiration date

I Agree

I hereby authorize Sanvello to copyright in its name and to use, re-use, publish and re-publish, in perpetuity, my performance, appearance, likeness and voice (the “Performance”) recorded in photograph, videotape, audiotape, film or any other medium, or reproductions or transcriptions thereof in any medium and to edit the same at Sanvello’s discretion, without restriction as to changes or alterations, and to include it with the Performances of others and with sound effects, still photography, graphics, special effects, digital effects and music. I understand the Performance may be published on web sites, applications, and social media platforms of Sanvello.

I consent to the taking and use of the photographs, films, audio and/or video, or publishing of website content or other information as described above. I understand that I may be personally identified in any use of the above materials, including identifying me as receiving behavioral health therapy and support from Sanvello. I understand the information may be shared via electronic posting and mentions–including web sites and social media (including but not limited to Facebook, Twitter, YouTube, etc.).

I hereby waive any right that I may have to inspect or approve any works that may incorporate use of my photograph, video or information.

I hereby release, discharge and agree to hold harmless Sanvello, its legal representatives and assigns, and all persons acting under its permission or authority, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the reproduction of such photographs or video, or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for defamation or invasion of privacy.

I understand and agree that I will not receive any payment for the use of the photo, video or story whether distributed by print, web site, social media, or other electronic publication or other means.

I am over 18 years of age. I have the right to contract in my own name. I have read the above consent and release and I am familiar with its contents. This consent release is binding upon the undersigned and his or her heirs, legal representatives and assigns.

I Agree