HonorHealth Media Authorization

* 1. The Undersigned hereby authorizes HonorHealth (“HONORHEALTH”), or the above hospital, or anyone authorized by HONORHEALTH to:

1. Act as an intermediary, making it possible for (name/agency) to interview, quote, and/or photograph still or film for purposes of publication in newspapers, magazines, or other printed media or for broadcast by means of radio or television transmission, social media, or for use on the intranet or internet or any other medium deemed appropriate by HONORHEALTH

2. Use the above person’s name in connection with any electronic or print publications (including but not l i m i ted to newspapers, television and/or radio broadcasts, books, brochures, magazines, motion pictures, and web and/or social media sites) for publicity, fundraising, scientific or educational purposes in such manner and at such times and in such places as HONORHEALTH or the person authorized by HONORHEALTH shall determine.

3. Use any quotation and comment made verbally or has already been taken. HONORHEALTH’s Notice of Privacy Practices explains the process for revocation, which includes a designated representative concerning the above-named patient and such patient’s medical case.

4. Take and reproduce in photographic or digital form pictures, slides and audio/video recordings of the abovenamed person in connection with the diagnosis, care and treatment ( including surgical procedures) or departmental functions at the above-named facility. HONORHEALTH

5. Use such pictures, slides and audio/video recordings in any electronic or print publication (including but not limited to newspapers, television and/or radio broadcasts, books, brochures, magazines, motion pictures, and web and/or social media sites) for publicity, fundraising, scientific or educational purposes in such manner and at such times and in such places as HONORHEALTH or the person authorized by HONORHEALTH shall determine.

I understand that I may refuse to sign this authorization form and that HONORHEALTH will not change or deny treatment based on my signing or not signing this authorization.

I understand that if information is disclosed to a third person, including media, that the information can no longer be protected by state and federal regulations, and may be redisclosed by the person or organization that receives the information

I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. HONORHEALTH’s Notice of Privacy Practices explains the process for revocation, which includes a tape recorded by the above-named person and/or his or her request in writing.

By checking this box, you release HONORHEALTH, its employees and agents, medical staff members and business associates from any legal responsibility or liability for disclosure of the above images and information to the extent indicated and authorized herein.