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I give permission to Advanced Physical Therapy & Sports Medicine, S.C. (Advanced) to use, or at Advanced’s election, choose not to use, my name and any affiliation, photograph, video, image, or likeness in conjunction with this review for marketing, advertising, and other similar purposes. I understand that this use may be in printed or electronic form and will continue until such use is terminated by Advanced, unless this authorization is otherwise revoked by me in writing to Advanced. I furthermore agree that this agreement shall be an authorization and consent for purposes of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other similar state laws such that the disclosure and release of any protected health information in this review is hereby authorized and consented to by my selecting YES. I hereby waive any right or any claim under state or federal law, including HIPAA, that the publication of this review is a violation of my rights under such laws or that I am entitled to compensation for such use. Please contact Marcus Werner at [email protected] with any questions.

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