I hereby do authorize and allow NuVasive, Inc. and any of its successors and/or assigns ("NuVasive") to use information concerning my surgical care involving NuVasive products for promotional and marketing purposes and hereby agree to, and acknowledge my understanding of, the following:
1. That NuVasive, Inc. intends to disclose to the public such information only as necessary for promotional and marketing purposes, and information that is disclosed will be publicly disseminated through various forms of media.
2. That "promotional and marketing purposes" involves any form of communication media, including but not limited to the production of promotional videos, compact discs, digital video discs, press releases, news stories, product brochures, and company Web pages.
3. That "information concerning my surgical care" includes any information related to treatment with NuVasive products, including but not limited to my name, likeness, testimonials (in any form, including audio clips), radiographic information, and still photographs and/or video footage of my surgical procedure.
4. That this authorization shall permit NuVasive to use said treatment information for promotional and marketing purposes for as long as NuVasive deems necessary, which shall not exceed 50 years from the date of execution of this authorization.
5. That use and disclosure of my private health information is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and by regulations promulgated under HIPAA by the United States Department of Health and Human Services.
6. That such information as I authorize NuVasive to use for promotional and marketing purposes may be used and disseminated by recipients of said information for further marketing and promotional purposes, and such redisclosure by recipient is not protected by HIPAA.
7. That pursuant to 45 CFR§ 164.508(b)(5) I have the right to revoke and cancel my authorization at any time and for any reason, provided that:
a) The revocation is in writing, and delivered to the appropriate NuVasive contact; and
b) NuVasive has not taken action in reliance on my authorization (i.e. NuVasive has not already distributed promotional materials containing my information in reliance on my authorization).
8. That NuVasive may not condition treatment, payment, enrollment, or eligibility for benefits upon this authorization of use of my health information for promotional and marketing purposes.
Having read and understood the above rights and provisions concerning my authorization, I, hereby confirm my desire to authorize and allow NuVasive, Inc and any successors and/or assigns to use information concerning my surgical care involving NuVasive products for promotional and marketing purposes.
