Marketing Authorization Form

I hereby authorize Ashley to use and share my information as described above, with the following: § Ashley’s marketing department or anyone authorized by Ashley for media, marketing, promotional and/or advertising purposes. § Internet websites, printed promotional materials and social media sites such as Facebook.

I understand that my participation in the above activities may directly or indirectly identify me as a patient of Ashley and may reveal information about me and my health condition, treatment, prognosis, etc. By signing this form, I understand any health information obtained from the activities above will be used or shared for media, marketing, promotional and/or advertising purpose. That means my health information may be seen on websites, in written promotional materials or social media sites. Once my health information is published and/or posted, I understand other people or groups including Ashley may republish or repost it.

Re-disclosure: I understand that my information will no longer be protected once disclosed. This means that my information may be re-disclosed without asking my permission. I also understand that Ashley may have no control over the editing or use of information once disclosed. Revocation: I understand that I can change my mind and cancel this authorization at any time. If I want to change my mind, I must let Ashley know in writing to: 800 Tydings Lane, Havre de Grace, MD 21078. If I change my mind, I understand that Ashley will not be able to take back the information already used or disclosed under this form. I understand that I do not have to sign this form. If I refuse to sign this form, my medical treatment, payment, benefit eligibility, or enrollment activities will not be affected. I understand that participation is voluntary. I understand that I will not receive compensation for the use and/or disclosure of my information.

By signing below, I confirm that I have read and understand this form and that I had the opportunity to have it explained to me verbally. I confirm that I have had the opportunity to ask questions and that all my questions have been answered. I understand that I am entitled to a copy of this authorization after I have signed it. This authorization will expire 1 (one) year from today’s date. However, once my information is used or disclosed, I understand the media may continue to use and reuse my information collected under this authorization indefinitely.