Authorization for use and release of information and images

I, the undersigned, hereby consent to an interview (which may include my name and my medical information, including but not limited to my diagnosis) and/or the taking of photographs, or video of me or parts of my body during diagnostic and/or treatment sessions, operations, other surgical or medical procedures, and/or other hospital or physician-related activities including community engagement events. 

I consent to the use and release of such interviews, photographs, pictures, or video in any outlet deemed proper by Adena Health (“Adena”) or a media company working with Adena. I understand that such outlets may be made to the general public. I agree that any photographs or video of me may be modified or retouched in any way that Adena or its media partner may consider desirable. I understand that the purposes of the outlet may include marketing communications or news reporting.

I consent to the use and disclosure of my name and any of my comments in any written communications created by Adena or its media partner in any outlet Adena or its media partner deems appropriate, without restriction.

I waive all rights that I may have to any claims for payment or royalties in connection with any exhibition, televising, publication of photographs and/or video, or publication of news (including feature stories) or other articles, regardless of whether the publication is philanthropic or commercial and irrespective of whether a fee is charged in relation to the publication.

By signing below, I hereby release Adena, its affiliated entities, officers, directors, employees, consultants, and agents from any and all claims and liability in connection with the use of the materials or outlets described in this form.

I understand the information used or disclosed may be subject to re-disclosure by the individuals or entities receiving it, and would then no longer be protected by applicable privacy regulations.

My authorization to disclose the information set forth in this document will not expire; however, I understand that I have the right to revoke this authorization in writing at any time. I understand revocation will not apply to information that has already been used or disclosed in response to this authorization.

I understand that authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure health care treatment