Patient Authorization Form for Using PHI For Marketing

By clicking "I consent to receive marketing communications from Hello Cake Inc. and authorize my reviews are eligible to be used in marketing according to this patient authorization form."  you acknowledge the below and release all health information pertaining to your medical history, mental or physical condition, and treatment received, including demographic information.

You hereby authorize Hello Cake, Inc. on behalf of itself and its affiliated, contracted, or otherwise engaged professional practices for medical services, including M&D Integrations, Inc., and their agents, contractors, and representatives (hereinafter collectively “Hello Cake”)  to use your image, your name and/or likeness, video recording, audio recording, and personal testimony in articles, films, videotapes, books, portfolios, presentations, marketing materials and similar documents for Hello Cake’s marketing, promotion and advertising activities.  You hereby consent to the storage and sharing of your image, your name and/or likeness, video recording, audio recording and personal testimony for Hello Cake’s marketing, promotional, and advertising purposes.  

You understand that you have the right to revoke this Marketing Authorization, in writing, at any time by sending such written notification to Hello Cake at 1601 Perrino Place, Unit C, Los Angeles, CA 90023, Attn: Legal Department.  You understand that information used or disclosed pursuant to this Marketing Authorization may be subject to re-disclosure by the recipient of such information and may no longer be protected by Federal or State law.  However, State law may prohibit the person receiving your health information from making future disclosures of your information unless another authorization for disclosure is obtained from you, or unless such disclosure is specifically required or permitted by law.  Hello Cake will not condition your treatment on whether you provide authorization for the requested use or disclosure.

You understand that you have the right to: inspect or copy the protected health information to be used or disclosed as permitted under Federal or State law; refuse to check the "I consent to receive marketing communications from Hello Cake Inc. and authorize reviews made by me to be used on the website for promotional material." box; and receive a copy of this Patient Authorization for Using PHI For Marketing.  

This Patient Authorization for Using PHI For Marketing is valid until you are no longer a patient of Hello Cake, within five (5) years from the date indicated below, or applicable state law, whichever is earlier.  

You have read the above information and authorize Hello Cake to use or disclose the identified information for the purposes described herein.