MEDIA RELEASE FORM

Unless I otherwise specify, the information described above may be disclose to i-Health’s vendors and/or the general public in connection with publicizing the promoting i-Health, including in print publications, multimedia presentations, television advertising, on websites and social media sites, in any other distribution and educational materials.

I understand that i-Health will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization form.

I understand that I may revoke this authorization by sending a written request for revocation to i-Health’s Privacy Officer. If I revoke this authorization, i-Health will no longer use or disclose my medical information for the reasons covered by this authorization, except to the extent it has already relied upon this authorization. I understand that when i-Health discloses information pursuant to this authorization, the information may no longer be protected by federal or state privacy rules and may be subject to re-disclosure by the recipient of the information.

This authorization shall not expire unless requested by Patient or Patient Representative.

Infinite Health Collaborative (i-Health) is a group of local medical practices, independently owned and led by its physicians, with operating divisions representing several areas of expertise. Visit i-Health.com to view the practices that are a part of i-Health.