Media Consent Form

This is completely voluntary and up to me. My consent to the use of video and audio telephone conference is indefinitely. I will not receive compensation for the use of my image, likeness, appearance, and voice now or in the future. I authorize FHE Health, officers, owners, contractors, employees and alumni to use and disclose the following protected health information for marketing services: My full name, my age, my city and state of residence, my diagnosis, my prognosis, my inpatient/outpatient therapy, all my dates of service with FHE, the name of all the locations where health care was provided to me, the name of all my health care providers other than FHE Health, all my verbal and/or written testimonials and statements, and all my video, audio recordings and photographic images captured, created, maintained, and/or produced by me or by FHE Health relating to my experiences with FHE Health and/or the care I received from FHE Health. I understand and agree to the conditions outlined in this Video and Audio Telephone Conference release and consent form. I acknowledge that I am fully aware of the contents of this release and am under no disability, duress, or undue influence at the time of my signing of this document. By signing this consent, I do hereby acknowledge that I have read the foregoing and I fully understand its contents and significance.