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Tell us how high out-of-pocket costs are affecting you and your family. Use the form below or tweet us a video with the hashtag #RxInReach.
Authorization for Release of Photograph, Video, Voice, Use of Likeness or Printed Quotes or Statements
Authorization for use. By signing this electronic document I hereby release to the Advocates for Responsible Care, Inc. (“ARxC”) and its officers, agents, employees, independent contractors and/or affiliates the rights of my photograph, image, likeness, voice as recorded on video or film, and any oral or written statement(s), that I submit through the “Rx in Reach GA” website, regardless of format (whether they are direct quotes or paraphrased by ARxC), for use by ARxC for the purpose producing and publishing public interest videos, and collateral materials, including hard copy, audio and television broadcast, and Internet publications.
Use of testimonial/photo/video. I understand that my photographs, images, likeness, voice as recorded on video or film testimonials and reproductions may be used in the production of materials used to promote ARxC’s public interest awareness campaign, “Rx in Reach GA”, concerning the practice of insurance companies moving medications to “specialty tiers” and their high out of pocket costs, by means of distribution via the Internet, hard copy, audio and television broadcasts, and, or at presentations made by ARxC at public or private events, or by ARxC in general, in perpetuity. I waive any right that I may have to inspect and approve the finished product that may be used or to which it may be applied now and/or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image or product.
Permission to revoke. At any time, I may revoke this permission by contacting ARxC. This revocation stops all future use of photos, videos and testimonials. I also understand that the choice of which reproduction is to be used, if any, is at the discretion of ARxC, and that the decision will be based on artistic merit, specific design needs, technical requirements, and marketing and communication strategies. I also understand that I do not have copyrights to any photographs, video or electronic reproductions published by ARxC.
I further acknowledge that:
(1) I am a person of legal age and the person identified below who is authorized to execute this release;
(2) I have read this release in its entirety;
(3) I fully understand and accept its terms; and
(4) I have executed this release voluntarily.