By completing this form, I hereby authorize Brightline, Inc. and Brightline’s affiliated medical groups (“Brightline”) to use and disclose my quote as written (my “Quote”) on the website, https://www.hellobrightline.com, and in any documents, images, or other materials Brightline shares with third-parties for marketing, advertising, education, or other related purposes. I understand and agree that Brightline may share my Quote with others, even if it contains content or images that convey information about the identity or health of my child such as my child’s name, age, or the type of care received. I understand and agree that:
- I can obtain a copy of this authorization or revoke it at any time by contacting firstname.lastname@example.org and submitting a written request. Removing this authorization will not affect any disclosures of my Quote that were made in reliance on this authorization.
- My Quote may be redisclosed by others who are not subject to the federal health information privacy laws.
- This authorization will expire one year from the date it is signed.
- Brightline will not condition treatment, payment, or eligibility for services on receiving this authorization.
- I hereby release Brightline from all claims, damages, and expenses arising from the use of my Quote as herein specified.
I am legally authorized to grant this authorization, which I have read and understood, as my child’s personal and legal representative.