Authorization for release and use of patient information, video(s) and photo(s).

Tactile Medical is requesting your permission to obtain, use and disclose your protected health information for purposes including marketing, advertising, sales and reimbursement. For example, Tactile Medical may use your information for patient stories or case studies, to discuss how our devices have helped you, to show photos demonstrating before and after results, to create brochures, and use your testimonials or comments about our company or products.

By signing below, you authorize Tactile Medical to use and disclose your relevant health information, photos, likeness, video, quotations, written and/or oral testimonial, comments, and the like in its marketing, advertising, sales and reimbursement. For example, Tactile Medical may use your testimonial or comments about our company or products in a case study or brochure, which may or may not include photos demonstrating before and after results. By signing below, you understand that Tactile Medical may publish, release, distribute, or otherwise make available your information to companies working with Tactile Medical and individuals outside of Tactile Medical. Tactile Medical may utilize electronic as well as paper means to distribute your information.

This authorization and release is granted indefinitely unless and until you revoke it. You can revoke your authorization at any time if you change your mind by writing to our Compliance Officer:

Tactile Medical Compliance Officer
3701 Wayzata Blvd, Suite 300, Minneapolis, MN 55416

If you revoke your authorization, it will not affect any actions Tactile Medical took before receiving your letter.

A photocopy of this form is as valid as the original to allow use and release of your information.

I’d like to speak with a compliance representative about a privacy concern or request.

Yes

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By signing the box above, you authorize Tactile Medical to use and disclose your relevant health information, photos, likeness, video, quotations, written and/or oral testimonial, comments, and the like in its marketing, advertising, sales and reimbursement. For example, Tactile Medical may use your testimonial or comments about our company or products in a case study or brochure, which may or may not include photos demonstrating before and after results. By signing below, you understand that Tactile Medical may publish, release, distribute, or otherwise make available your information to companies working with Tactile Medical and individuals outside of Tactile Medical. Tactile Medical may utilize electronic as well as paper means to distribute your information.

This authorization and release is granted indefinitely unless and until you revoke it. You can revoke your authorization at any time if you change your mind by writing to our Compliance Officer:
Tactile Medical Compliance Officer
3701 Wayzata Blvd, Suite 300, Minneapolis,
MN 55416

If you revoke your authorization, it will not affect any actions Tactile Medical took before receiving your letter.