Consent for Publishing Photographs and/or Recordings

1. I, the undersigned, a participant in the production and videotaping (or other recording) at Orlin & Cohen Orthopedic Group (or the parent, legal guardian, or person otherwise authorized to consent to such participation), hereby consent to the taking of any and all still photographs, motion pictures, television and/or videotapes, voice recording, and/or other recordings ("Recordings") of my/his/her person at Orlin & Cohen (the “Practice”) during the course of my/his/her participation in (the "Event") agree to the use of the Recordings as follows:

For any educational, training, contribution solicitation, marketing, promotional or other purpose, in any medium whatsoever, by the Practice and/or by any person or persons the Practice may name: and/or for any broadcast or other public viewing. Such Recording may be used as described above, in full or edited form, and may be incorporated into other recording or formats and may be copied for multiple distributions and/or broadcast.

2. I agree that I will receive no compensation or other remuneration for the taking, production, use, broadcast, and/or distribution of such Recordings or for my participation in any manner in such Event, and I specifically release the Practice and all others from any liability or other obligation arising from the taking, production, use, broadcast, and/or distribution of such Recordings and from my participations in the Event.

3. I understand that I have the right to withdraw from participating in the Recording at any time during the Event and that I have the right to revoke this consent at any time to the extent that the Practice and/or its designee have not relied upon it or has not submitted the Recording for use in external media.

Note: If the participant is under (18) years, the permission of the participant’s parent, legal guardian, or authorized person is required. If the participant decides to revoke his or her authorization, please write to Orlin & Cohen Orthopedic Group, 1728 Sunrise Highway, Merrick, NY 11566, as soon as that decision is made.

Terms and Conditions

We understand that information about you and your health is personal and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your written authorization before we may use or disclose your protected health information for the purposes described below. This form provides that authorization and helps us make sure that you are properly informed of how this information will be used or disclosed. Please read the information below carefully before agreeing to the terms of this authorization.

Who will use and disclose my information? Orlin & Cohen will disclose the information you submit about your Orlin & Cohen experience by electronically posting it to www.orlincohen.com and/or Orlin & Cohen social media channels. Orlin & Cohen will send you messages regarding the status of your submission through the email service provider of Orlin & Cohen’s choosing. Orlin & Cohen may use the information you submit to contact you to request permission to use the information you submit about your Orlin & Cohen experience for other purposes. Orlin & Cohen may also use the information you submit about your Orlin & Cohen experience for: (i) educational, training, and/or promotional purposes at Orlin & Cohen and/or at any other location(s); (ii) publicity, advertising (print, digital, and/or television), publications, and/or solicitation of contributions; and/or (iii) broadcast and/or other public display or viewing.

Who will see my information? Anyone visiting www.orlincohen.com and/or Orlin & Cohen social media channels may see or use the information you submit. Administrators of the email service provider Orlin & Cohen uses to send you status messages will also have access to limited information, primarily your email address. In addition, in the event Orlin & Cohen uses your information as described above members of the general public will see the information.

What information will be used or disclosed? The information used and disclosed will be limited to the information you submit through this website. The information posted/disclosed on www.orlincohen.com and/or Orlin & Cohen social media channels, or otherwise used and/or disclosed as described above, may include:

• Your name
• The city/town, state/province/territory, and country where you live
• The story of your care at Orlin & Cohen with information on your condition/injury, diagnosis, and treatment (including surgery if applicable)
• The name of your Orlin & Cohen physician(s), therapist(s) and other caregivers; and your photo and/or video

The information disclosed to Orlin & Cohen's email Service provider, and used by Orlin & Cohen to contact you, will include your:

• Name
• Email address

If you submit sensitive information, that information will be deleted from your submission prior to your story being posted to www.orlincohen.com and/or Orlin & Cohen social media channels, or if the sensitive information cannot be deleted from your submission without compromising the integrity of your story, Orlin & Cohen may decline to post your submission altogether. The following types of information are considered sensitive and will not be posted/disclosed:

• HIV-related information (which is any information indicating that you have had an HIV-related test, or have HIV infection, HIV-related illness or AIDS, or any information that could indication you have been potentially exposed to HIV)
• Substance abuse information
• Psychiatric/psychotherapy care information
• Sexually transmitted disease information
• Tuberculosis information
• Genetic information

What is the purpose of the use or disclosure? The purpose of the use or disclosure is to share your Orlin & Cohen experience.

When will this authorization expire? This authorization will expire 15 years from the date you submit it to Orlin & Cohen. After the expiration of this authorization, Orlin & Cohen will not use or disclose your health information for the purposes described herein, unless you authorize such additional use or disclosure by submitting another authorization.

By agreeing to the terms of this authorization, you authorize the use or disclosure of your protected health information, as described above. This information may be redisclosed if the recipient(s) described in this authorization is not required by law to protect the privacy of the information, and such information is no longer protected by federal health information privacy regulations. You have a right to refuse to agree to the terms of this authorization. Your healthcare, the payment for your healthcare, and your healthcare benefits will not be affected if you do not agree to the terms of this authorization, but we will not be permitted to disclose your information as described on this authorization without your agreement.

You have a right to receive a copy of this authorization after you have agreed to its terms. If you would like a copy of this authorization, please send your request to: Orlin & Cohen Orthopedic Group, 1728 Sunrise Highway, Merrick, NY 11566.

If you agree to the terms of this authorization, you will have the right to revoke it at any time, except to the extent that Orlin & Cohen has already taken action based upon your authorization. To revoke this authorization, please write to Orlin & Cohen Orthopedic Group, 1728 Sunrise Highway, Merrick, NY 11566.

Unless you represent below that you are the personal representative of an adult or minor patient, Orlin & Cohen will only post information about you. If you submit information about another patient or individual that could be considered protected health information, that information will be deleted from your submission prior to your story being posted to www.orlincohen.com and/or Orlin & Cohen social media channels, or if the information cannot be deleted from your submission without compromising the integrity of your story, Orlin & Cohen may decline to post your submission altogether.