AUTHORIZATION AND CONSENT
By checking the terms and conditions and submitting your testimonial to Hilltop Meds, LLC and Hilltop USA
Distribution LLC via the Paragon Method Virtual Portal, and their respective officers, employees, agents, or affiliates (the “Hilltop Recipients”) to use and/or disclose my personal health information to local, state, national, and international media outlets.
These media outlets may include newspapers, magazines, the internet, and social media sites. I specifically authorize the use and/or
disclosure of the following personal health information (“Personal Information”):
● Photographs of me, in digital or any other format, in whole or in parts; and
● My testimonial, in any form or medium.
I understand that the Hilltop Recipients may use and/or disclose any or all of my Personal Information for marketing,
publicity, communication, and other business purposes. I understand that I will receive no compensation for the use
of my Personal Information.
I understand that all photographs of me, including all reproductions, negatives, videos, or films, and my personal
testimony that forms part of my Personal Information remain solely the property of the Hilltop Recipients. The Hilltop
Recipients may copyright, publish and license photographs of me and my personal testimony. I understand that I
waive any right to see or approve the finished product that uses my photograph or testimonial.
I expressly release and agree to hold harmless each of the Hilltop Recipients from any and all claims arising out of, or
connected with, the use of my Personal Information.
I understand that, once any of the Hilltop Recipients use my Personal Information, media outlets and others who have
seen my Personal Information may not be subject to the same federal health privacy laws and may distribute any of
the above information.
I understand that the Hilltop Recipients may not condition my access to the Hilltop Med products and/or services on
whether I sign this authorization and consent. I understand that I am not required to sign this authorization and
consent and that my eligibility to use and/or purchase, as applicable, Hilltop Med products and/or services will not be
affected by my refusal.
I understand that this authorization and consent will remain in effect for ten (10) years. I understand that I may
revoke this authorization and consent at any point in time by giving the Hilltop Recipients a written revocation. I
understand that information released between the date of this authorization and consent and the date of revocation
may still be used in the public domain. I understand that I have the right to receive a copy of this authorization and