Authorization for Release of Information

When you sign up for an account at CES.UnitedHealthcareMotion.com, if you do not opt out of having your activity information included on the CES.UnitedHealthcareMotion.com site, your activity information and anything you post to the site (including forum comments), will be viewable by other users. These users may be able to identify you either through your chosen screen name or through the uniqueness of your information. Because this viewable information may include your health information and may identify you, Trio Motion, LLC (“TM”) requires that you provide an authorization to allow for this disclosure.

By agreeing, you certify that you:

1. Hereby authorize the use and disclosure of your activity information, CES.UnitedHealthcareMotion.com posts and selected screen name on CES.UnitedHealthcareMotion.com, which will be viewable by other users.
2. Understand that agreeing to this authorization is voluntary. Treatment or payment for any applicable health services is not dependent on this authorization. However, if you do not consent to this authorization and do not opt out of having your activity information displayed on the site, TM will not allow you to proceed with creating a CES.UnitedHealthcareMotion.com account.
3. Understand that you have a right to inspect a copy of this authorization and the information maintained by TM.
4. Understand that other users of CES.UnitedHealthcareMotion.com are not covered under federal privacy regulations and, therefore, the released information may no longer be protected by such federal privacy regulations.
5. Understand that you have a right to revoke this authorization, but that you must send a written revocation to Trio Motion, LLC, Attn: Customer Service, 6066 Shingle Creek Pkwy #279, Brooklyn Center, MN 55430. You also understand that the revocation applies only to uses and disclosures made after the revocation is made. Unless you revoke this authorization, the authorization will not expire.