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I acknowledge that the information disclosed in the Testimonial may include information protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), including information about my health, treatments, and progress. By signing this authorization, I am specifically authorizing Prescribe FIT to use this health information for marketing purposes, and I understand that once disclosed, the information may no longer be protected by HIPAA privacy regulations.

I hereby irrevocably authorize Prescribe FIT to copy, exhibit, publish, or distribute the Testimonial and health information for purposes of publicizing Prescribe FIT’s services or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites, or in any other distribution media. I agree that I will make no monetary or other claim against Prescribe FIT for the use of the statement.

In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my testimonial appears. I hereby hold harmless and release Prescribe FIT from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I have read the authorization and release information and give my voluntary and informed consent for the use of my testimonial and health information as indicated above.

Revocation of Authorization:

I understand that I may revoke this authorization at any time by providing written notice to Prescribe FIT at the following contact information:

Prescribe FIT, Inc.
401 West Town Street, Suite 232
Columbus, Ohio 43215

This revocation will be effective except to the extent that Prescribe FIT has already taken action in reliance on this authorization. I also understand that the revocation will not apply to information that has already been disclosed in reliance on this authorization prior to receipt of the revocation.