Saint Joseph Health System Corporate Identity and Graphic ...

Saint Joseph Health System 

Corporate Identity and Graphic 

Standards Manual

Genes Letter 

2

100. Introductory letter from Gene Woods 

101. Table of Contents 

102. CHI System Logo; SJHS Fonts & Colors 

103. Saint Joseph Health System Branding & URLs 

104. Campus Names and Programs 

105. Exterior Signage 

106. Physician Marketing 

107. Advertising and Marketing Policies 

108. Internal Communication 

109. Public Communication 

110. Glossary 

102. CHI System Logo verification 

Fonts 

Colors 

Saint Joseph Health System PR, Communications & Marketing Team 

Name Location 

Jeff Murphy, PR, Communications & Marketing Regional Director Saint Joseph Hospital 

Stephanie Sarrantonio, Marketing Coordinator Saint Joseph Hospital 

Kevin Smith, Interactive Marketing Coordinator Saint Joseph Hospital 

Liz Sword, Graphic Designer / Publications Coordinator Saint Joseph Hospital 

Kara Fitzgerald, Internal Communications Coordinator Saint Joseph Hospital 

Angela Florek, Project Coordinator Saint Joseph East 

Stacey Paredez, Administrative Assistant Saint Joseph Hospital 

Sharon Hershberger Saint Joseph - London 

Tonya Lewis Saint Joseph - London 

Katie Heckman Saint Joseph – Berea 

Neva Francis Saint Joseph – Martin 

Amy Taylor Flaget Memorial Hospital 

Cindy Clark Saint Joseph – Mount Sterling 

3

4 

CHI's symbol is a cross — simple, almost star-like, representing CHI's faith and foundation. The 

cross is used with the Catholic Health Initiatives name, or logotype, to form the system's logo. Each 

MBO uses the CHI logo, along with its own name, on stationery items and other print materials. 

CHI's colors provide another strong element of its brand identity, as does its theme line, "A spirit of 

innovation, a legacy of care." 

The signature is a fixed relationship of all the design elements, including CHI's system symbol (the 

cross) and logotype (the words Catholic Health Initiatives) plus the name of a CHI MBO in its 

appropriate typography, all positioned in a consistent hierarchy as follows: 

This hierarchy never changes, regardless of the signature application: the CHI system symbol (the 

cross) and logotype (the words Catholic Health Initiatives) are always first in order of appearance 

with the local MBO name second in order, however, prominently displayed through a greater weight 

and size of typography. How the MBO name appears (bold, set off with rule lines, etc.) can vary 

based on the signature's application on stationery items, print materials and advertising. This 

signature approach supports CHI's branding strategy to consistently feature the CHI system symbol 

and logotype first in order but to give visual emphasis to the MBO name, thus optimizing its brand 

equity in the local market. 

Acceptable fonts for Saint Joseph Health System marketing and communication pieces: 

Adobe Garamond Pro 

Avenir LT Std Series 

ENGRAVERSGOTHIC 

Futura 

Giovanni Book 

GoudySans 

Helvetica Neue LT Std 

Humanst521 BT 

Lydian BT 

Lynda 

Myriad Series 

NewBaskerville 

Optima 

SACKERS GOTHIC STD 

Times New Roman 

Other possibilities: 

System Symbol and Logotype 

Amaze 

Angelina 

Basil 

BaskervilleT 

Black Chancery 

BrockScript 

Clearface 

Century Gothic 

Cocktail 

Daniela 

Franklin Gothic Book 

Freehand471 BT 

Geometr231 BT 

Gill Sans 

JohnHancock 

Kaufmann BT 

Kids 

Marydale 

MBO Name

Metrostyle 

Micro technic 

MurrayHill 

NewsGothic 

Phinster 

Snell BT 

TRAJAN PRO 

Veljovic Medium 

ZaphChan BD BT 

Colors: 

It is the recommendation of Saint Joseph Health System marketing department that the logo be in 

black or reversed out (white logo on black background, e.g.) 

(See Appendix A) 

Signature Lines: 

The recommended format for e-mail “siglines” is to include your name, title, contact information 

(including e-mail address) and URL. Using the facility’s logo is optional. Below is an example. 

Name 

Job Title 

1 Saint Joseph Drive | Lexington, KY | 40504 

Direct: (859) 313-XXXX | Fax: (859) 313-XXXX 

youremail@sjhlex.org | www.saintjosephhealthsystem.org 

103. Saint Joseph Health System Branding 

Saint Joseph is always spelled out. Never abbreviate “St.” or “Joe’s.” 

Unacceptable terms include: 

Main campus 

Saint Joseph Main 

Saint Joseph West (it is Saint Joseph Hospital) 

Saint Joseph Health Care (it is Saint Joseph Health System) 

Saint Joseph’s Hospital (there is no ‘s on Joseph) 

Saint Joseph Health Systems (there is no s after System) 

Employees are no longer referred to as associates; they are called employees (lowercase “e”). 

“Saint Joseph” not “St. Joe’s”, should always be used when addressing groups 

Make sure all employees are aware of branding basics. 

Naming, renaming or branding of services must be coordinated through the marketing 

representative of the applicable facility. 

In print material, including brochures, the name of the hospital is to appear first, then the service or 

center appears second. 

A hyphen is used between “Saint Joseph” and the campus designation (excluding Saint Joseph 

Hospital and Saint Joseph East. These two facilities DO NOT use the hyphen). 

Ex: Saint Joseph - Berea 

There is one space before and after the hyphen. Do not use an en dash or em dash. 

5

In headlines and logos, if the name of the hospital is in a very large font and requires two lines the 

hyphen is not used. 

Ex: SAINT JOSEPH 

LONDON 

For all external communication, including patient publications, always spell out the full names of 

hospitals and services. 

URLs: 

In print instances (e-mail and marketing materials, e.g.) capitalize the first letter of each word in a 

URL. Do Not use sjhlex.org when giving out the web address (our official Web address is 

SaintJosephHealthSystem.org). 

BereaFamilyMedicine.org 

Flaget.com 

KnowMyHeart.com 

KnowYourHealthKentucky.com 

KnowYourHealthKY.com 

SaintJosephBerea.org 

SaintJosephBreastCenter.org 

SaintJosephCommonThread.org 

SaintJosephDaVinci.org 

SaintJosephEastKY.org 

SaintJosephHealthSystem.org 

SaintJosephHospitalKY.org 

SaintJosephJessamine.org 

All the .me addresses need to be listed. 

104. Campus Names and Programs 

SaintJosephLondon.org 

SaintJosephMartin.org 

SaintJosephMaternityFair.com 

SaintJosephMountSterling.org 

SaintJosephNurses.org 

SaintJosephPhysicians.org 

SaintJosephRobot.org 

SaintJosephSleep.org 

SaintJosephVolunteers.org 

SaintJosephWeightLoss.org 

SaintJosephMedworks.org 

SaintJosephDigestiveHealth.org 

As of February 23, 2009, there are 8 hospitals within Saint Joseph Health System. 

Flaget Memorial Hospital 

4305 New Shepherdsville Road 

Bardstown, KY 40004 

502.350.5000 

Established 1951 

Programs: 

Cardiac Care and Rehabilitation 

Emergency Trauma Unit 

Flaget Birth Center 

Gynecology Services 

Imaging Services 

Laboratory Services 

Oncology/Cancer Care 

Pain Management Center 

Pulmonary Rehabilitation 

Sleep Wellness Center 

Surgical Services 

Wound Center 

6 

Deleted: ; purchased by SJHS in 2008. 

Deleted: Oncology Center 

Rehabilitation services 


Surgical services

Hospitalist Program 

Flaget Medical Office Bldg 

Suite 205 

Audiology 

Gastroenterology 

Neurosurgery 

Neurology 

Oncology 

Pulmonology 

Urology 

Center for Weight Loss Surgery 

Off-Site Services 

Flaget Immediate Care Clinic 

Flaget Health Connection 

Hospice of Nelson County 

Physical, Occupational and Speech Therapy 

Saint Joseph Hospital 

1 Saint Joseph Drive 

Lexington, KY 40504 

859.313.1000 

Established 1877. 

Programs: 

Breast Center 

Cancer Center 

Corporate Health Services 

da Vinci Surgery 

Heart Institute 

MedWorks 

Outpatient & Diagnostic Services 

Pain & Rehabilitation Center 

Park Physical Therapy 


Wound Center 


Saint Joseph - Berea 

305 Estill Street 

Berea, KY 40403 

859.986.3151 

Established 1898 as Berea Hospital 

Programs: 

Berea Family Medicine 

Berea Specialty Clinic 

Breast Center 

Diabetes and Nutrition Center 


Rehabilitation Services 


7 

Deleted: 

Deleted: Outpatient Rehabilitation 

Services 

Deleted: . 

Deleted: Purchased by Saint Joseph 

Health System in 2005.


Surgical Services 

Saint Joseph East 

150 N. Eagle Creek Drive 

Lexington, KY 40509 

859.967.5000 


Programs: 

Breast Center 

Center for Weight Loss Surgery 


MedWorks 

Joint Care Center 

Kid Traxx (pediatric emergency center) 

Outpatient Rehabilitation Services 


The Women's Hospital at Saint Joseph East 

Voice & Speech Center 


Saint Joseph - Jessamine RJ Corman Ambulatory Care Center 

1250 Keene Road 

Nicholasville, KY 

859.887.4100 

Opened 2009 

Programs: 

Diagnostic imaging 

Lab services 

Saint Joseph - London 

310 E 9th Street 

London, KY 40741 

606.878.6520 


Programs: 

Express Medical Imaging (MRI & CT Scans) 

London Pediatric & Adolescent Medicine 

Saint Joseph - London Express (Outpatient Lab and X-Ray testing) 

Seton Home Health 


Saint Joseph Hospice 


Saint Joseph - Mount Sterling 

50 Sterling Avenue 

Mt. Sterling, KY 40353 

859.498.1220 


Programs: 

Diabetes Treatment Center 

8 

Deleted: SJHS in 2008. 

Deleted: Purchased by SJHS in 2007.

Gateway Physical Therapy 

Gateway Surgical Associates 

Joint Care Center 


Saint Joseph Outreach Clinic - Owingsville (formerly Bath Family Health Services) 

Saint Joseph - Martin 

11203 Main Street 

Martin, KY 41649 

606.285.6400 

Established: 1947. 

Programs: 

Clinical services 

Pastoral care 

Social work 

Swing Bed 

Community Health Education 


Dr. Ghassan Shakhashiro - Hospitalist 

FAMILY PRACTICE LISTING 

Betsy Layne Clinic 

9350 US Highway 23 South, Suite 3 

Stanville, KY 41659 

606.478.3636 

Bill Webb, D.O. 

Monday - Thursday 8 a.m. - 6:30 p.m. 

Friday - Closed 

Martin Clinic 

12579 Main Street, Suite 101 


606.285.0681 

Monday - Thursday 8 a.m. - 4:30 p.m. 

Friday - 8 a.m. 12 noon 

Seton Family Health Center 

Seton Complex 


PO Box 910 


606.285.3690 or 606.285.9989 

Monday - Friday 8:30 a.m. - 5 p.m. 

John Triplett, D.O. 

Prem Verma, M.D. 

Mike Williams, PA-C 


Seton Complex 


9 

Deleted: . Purchased by SJHS in 2008 

Deleted: James Hager, D.O. Mountain 

View Family Health Center 


PO Box 910 


606.285.9426 

Monday - Friday 8 a.m. - 4:30 p.m. 

Prem Verma, M.D. 

Mike Williams, PA-C 

Deleted: Donald Morando, D.O.

PO Box 910 


606.285.3851 

Monday - Thursday 7:30 a.m. - 4 p.m. 

Lowell Martin, M.D. 

Wheelwright Family Health Center 

1403 KY Route 306, Suite 102 

Wheelwright, KY 41669 

606.452.2300 

Monday & Tuesday 8:30 a.m. - 5 p.m. 

Wednesday 1 p.m. - 9 p.m. 

John Triplett, D.O. 

Family Practice 

PEDIATRIC LISTING 

Physicians for Children and Teens 


Seton Complex 


PO Box 910 


606.285.1442 

Monday - Friday 8:30 a.m. - 5 p.m. 

Rakesh Sachdeva, M.D. 

Seema Sachdeva, M.D. 

Adnan Idrees, M.D. 

105. Exterior Signage ADD EXAMPLES 

All signage on the buildings will be approved by the local marketing department, including signs 

directing patients and visitors to certain locations or depicting the name of a particular service. 

Insert verbiage for CHI Standards Manual reference. 

106. Physician Marketing 

Since January 1, 1992, it is illegal for physicians and health care facilities to participate in selfreferrals, 

as they are considered to be a conflict of interest. The “Stark Law” is a provision of the 

Omnibus Budget Reconciliation Act (OBRA) of 1989, and was named after its sponsor, 

Representative Forney “Pete” Stark (D-CA). 

PHYSICIAN MARKETING ACTIVITY MATRIX 

Use Notes 

� If not otherwise specified in the physician marketing activity description, “publishing” includes use of any communications media, including but not 

limited to electronic media, newspapers, brochures, circulars, yellow pages, newsletters, and websites. 

� Be certain that information provided on the Hospital website or print media is accurate and uses appropriate disclaimers for physician supplied 

information. Avoid any use of comparative, qualitative or warranty type representations. 

� Avoid any endorsement of a product or supplier unless the practice is consistent with MBO or CHI policy. 

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� This matrix is designed to primarily address the Stark Law implications of physician marketing activities and is not intended to cover all 

applicable federal and state law. The physician marketing activity should also be reviewed for compliance with state and federal truth in advertising 

laws (i.e., Lanham Act), State Boards of Medical Practice limitations and regulations and state laws on apparent agency. 

Physician Marketing 

Activity 

� �� 

Yes Caution Not allowed 

1. Publishing all medical staff member names, 

photo, office address and area of specialty 

in Hospital Medical Staff Directory. 

2. Publishing all medical staff member 

names, photo, office address and area 

of specialty on Hospital web site. 

3. Publishing name, photo, office address and 

area of specialty in Hospital web site with 

web link to Physician’s private practice web 

page. 

4. Create a special section on the Hospital’s 

web page or banner advertising of a 

particular service line with the physician’s 

name, office address and other information 

about the physician’s services (such a 

bariatric or cardiac surgery programs). 

5. Provide free assistance in ad layout, design 

and placement for print or web advertising 

for physicians on the Hospital Medical Staff 

(existing or new medical staff members). 

6. Publish an article on a Hospital service with 

brief quotations from a Hospital or 

community physician about the medical 

service at the Hospital. 


the physician prominently featured with 

quotations, office contact information and or 

fee information. 


the physician paying fair market value based 

on the costs of the layout, placement fees, 

and other charges for the service based on the 

percentage of the article referencing the 

physician vs. the hospital service. 

EMPLOYED 

PHYSICIANS 

PHYSICIANS UNDER 

CONTRACT WITH THE 

HOSPITAL TO PROVIDE A 

SERVICE BUT THE 

HOSPITAL BILLS AND 

COLLECTS FOR THE 

PROFESSIONAL SERVICES 

11 

ALL OTHER PHYSICIANS 

(PHYSICIANS UNDER CONTRACT 

WITH THE HOSPITAL TO 

PROVIDE A SERVICE BUT THE 

PHYSICIAN BILLS AND 

COLLECTS FOR PROFESSIONAL 

SERVICES) i 

� � �Incidental medical staff 

benefit. 2 

� � �Incidental medical staff 

benefit. 

See footnote #2. 

� ��Hospital owned service 

lines. 3 


lines. 



lines. 


� ��Rotate the physicians 

selected. .. 

� �� 

Hospital owned service 

line and rotate physicians 

selected. . 

��This area of the law is unsettled. 

The recommended approach is to 

include the web link cost in the 

annual $300 limit per physician or 

charge a fair market value fee. 4 

�This practice would only be 

allowed if the Hospital charges the 

physician fair market value for the 

advertising. 5 

� 

��Allowed, but consider how much 

of the article is devoted to 

promoting the physician’s private 

practice of medicine as opposed to 

general medical information useful 

to the public. Rotate the physicians 

selected. 

�This approach may cross the line 

from incidental medical staff 

benefits to the unpaid promotion of 

a physician’s private practice of 

medicine. 

� � �Ok, but recommended to print a 

disclaimer that the ad was paid for 

by both parties.

Physician Marketing 

Activity 

� �� 

Yes Caution Not allowed 

9. Publish an announcement for new physicians 

on the Hospital medical staff (only once and 

for all new physicians joining the medical 

staff). 

10. Provide free or below cost hospital 

advertising services for a newly recruited 

physician while the physician is under a 

Recruitment Agreement with the hospital. 

11. Publish a hospital ad that includes photos of 

physicians on staff in 

that service line (picture of OB physician 

with nursing staff on OB unit). 

12. Product manufacturers or third parties offer 

free or discounted advertising (based on 

purchasing practices or not) which may 

mention Hospital by name. 

13. Provide an advertisement for a joint venture 

with a physician. 

EMPLOYED 

PHYSICIANS 

PHYSICIANS UNDER 

CONTRACT WITH THE 

HOSPITAL TO PROVIDE A 

SERVICE BUT THE 

HOSPITAL BILLS AND 

COLLECTS FOR THE 

PROFESSIONAL SERVICES 

� � � 

12 

ALL OTHER PHYSICIANS 

(PHYSICIANS UNDER CONTRACT 

WITH THE HOSPITAL TO 

PROVIDE A SERVICE BUT THE 

PHYSICIAN BILLS AND 

COLLECTS FOR PROFESSIONAL 

SERVICES) i 

N/A N/A � The only way this service could 

be provided is to charge back the 

fair market value of the service to 

the physician or group. 


line and should rotate 

physicians selected. 

� �� 

��Gray area. Best practice is to 

rotate physician selected in the 

picture and rotate among all 

significant hospital service lines, not 

just high referring service lines. 

N/A N/A � The activity is not permitted 

unless the costs are fully charged 

back and allocated in accordance 

with the percentage of ownership of 

the joint venture. 

1 The term “all other physicians” includes non-employed, independent medical staff members and hospital/physician 

joint ventures such as imaging and ambulatory surgery centers. 

2 Under the incidental medical staff benefits exception under Stark Law, the Hospital may provide members of the 

medical staff with items or services (non-cash) on campus so long as it is not based on the volume or value of referrals; 

is reasonably related to the provision of medical services and the Hospital’s mission, is less than $25 per occurrence (or 

is calculated into the $300 annual limit of non-monetary compensation) and the item or service is consistent with the 

types of benefits offered by other hospitals within the same local region. 

3 When the hospital owns the service line and bills and collects for the physician’s professional fees, the hospital may use 

the fair market value or personal services exception under Stark. One key requirement of the fair market value and 

personal services exception is that the agreement between the parties be in writing for the services or items provided, 

among other requirements. 

4 Under the non-monetary compensation exception under Stark Law, up to $300.00 per year, (non-cash) per physician, 

may be provided if all of the following conditions are satisfied: (i) the amount of the advertising support provided is not 

based in any manner that takes into account the value of volume of referrals or other business generated between the 

parties, (ii) the money is not solicited by the physician or the physician’s practice (including employees and staff 

members), (iii) the compensation arrangement does not violate the anti-kickback statue or any federal or state law 

governing billing or claims submission. The Hospital must have a system to track the item or service provided annually 

per physician. 

5 Fair market value under Stark and the anti-kickback law is essentially the same; the value of the advertising services 

being provided in an arms-length transaction when the buyer and seller are not otherwise in a position to generate 

business for the other party. In other words, the value or cost of the advertising services is consistent with the cost of 

services purchased from a commercial advertising agency or at least the cost to the hospital providing the services if 

there is no comparable service that can be purchased from an outside vendor. Under the fair market value exception to 

�

Stark (assuming another exception does not apply), all advertising services or items being provided must be in 

writing; the value of the services being provided and payment expected; the agreement must specify the time period 

covered; and the value of the services must not take into consideration the value or volume of referrals between the 

parties. 

107. Advertising and Marketing Policies 

All marketing projects follow an approval process. It starts with a request made by an 

administrative or service line representative that is sent to the marketing representative for that 

campus, who works with the system office creative team. A draft is then approved by the client 

(service, e.g.), then the president and/or marketing representative of the facility approves it and 

sends to the system office creative team. Jeff Murphy has final approval. 

All marketing activity, including media buying and creative, must be coordinated through the Saint 

Joseph Health System marketing department. 

All promotional items (T-shirts, pens, etc.) are purchased or approved through Angela Florek, 

aflorek@sje.sjhlex.org, or the marketing representative at the appropriate facility. 

[include the template form used in marketing] 

108. Internal Communication 

Common Thread magazine: www.SaintJosephCommonThread.org 

inCommon electronic newsletter: www.SaintJosephHealthSystem.org/InCommon 

The Daily Line-Up stand-up meeting 

eMed physician electronic newsletter: www.SaintJosephPhysicians.org 

Common Thread is an 8.5” x 11” glossy magazine published 6 times a year. It is distributed to all Saint 

Joseph Health System employees, key CHI employees and displayed in waiting rooms and public 

areas throughout the system. It is available online for public viewing at 

www.SaintJosephCommonThread.org. The magazine’s content focuses on employees and their 

outreach inside and outside Saint Joseph Health System. Kara Fitzgerald is the editor: 

fitzgekl@sjhlex.org, 859.313.1845. Story ideas and suggestions may be sent to her directly or 

submitted online at www.SaintJosephCommonThread.org. 

inCommon is a weekly electronic newsletter containing details and short reports about organizational 

news, along with photos of recent events. It is sent to all Saint Joseph Health System employees’ 

work e-mail addresses. Issues of the newsletter are archived at 

www.SaintJosephHealthSystem.org/InCommon. Content is coordinated through Kara Fitzgerald: 

fitzgekl@sjhlex.org, 859.313.1845. 

The Daily Line-Up is delivered face-to-face Monday through Friday by department leaders to 

employees across Saint Joseph Health System. It is a standup five-minute presentation for new 

policies and procedures, daily information and breaking news within the organization. It consists of 

system news and facility news: system news is shared with all employees and facility news is 

customized according to the individual facility (exception: Saint Joseph Hospital, Saint Joseph East 

and Saint Joseph - Jessamine share the same facility news). Content is coordinated through Kara 

Fitzgerald: fitzgekl@sjhlex.org, 859.313.1845. 

13 

Deleted:

14 

eMed is an electronic newsletter for physicians within Saint Joseph Hospital, Saint Joseph East 

and Saint Joseph - Jessamine. It is distributed monthly and as-needed with late-breaking news and 

information. It is available online for viewing at www.SaintJosephPhysicians.org. Content is 

coordinated through Cynthia Salamanca: salamac@sjhlex.org, 859.313.1096. 

For internal communications, spell out the facility’s full name on first reference. The initialism is fine 

on second reference. 

Saint Joseph Health System (SJHS) 

Saint Joseph - Berea (SJB) 

Saint Joseph East (SJE) 

Flaget Memorial Hospital (FMH) 

Saint Joseph Hospital (SJH) 

Saint Joseph - Jessamine (SJJ) 

Saint Joseph - London (SJL) 

Saint Joseph - Martin (SJM) 

Saint Joseph - Mount Sterling (SJMS) 

109. Public Communication 

News releases: 

Any news-worthy information of public interest can be sent to the appropriate campus marketing 

representative (see page 3), who will send out news releases to the media when appropriate. 

A release form must be signed by any patient or person who agrees to appear in a photograph. 

Facility representatives are to scan and e-mail a copy of each release, including date(s) and details of 

the project to Stacey Paredez. 

Crisis communication: 

Don’t contact a media outlet for anything related to sales or news or public relations. Contact the 

local marketing representative (see page 3) of the facility in question. This person will then work 

with Jeff Murphy, who is the spokesperson for Saint Joseph Health System. No one other than Jeff 

or his designated marketing representative should be communicating with the media.

Photo release form: 

PURPOSE OF AUTHORIZATION: CATHOLIC HEALTH INITIATIVES 

Attached is an authorization form for use by Catholic Health Initiatives (“CHI”) to obtain 

authorization to photograph and/or interview (as defined in the form) a patient or patient family 

member at one of its Market-Based Organizations (“MBOs”), visitors, employees, independent 

contractors or other persons who may or may not have association with CHI or one of its MBOs. 

The form should not be used by a skilled nursing facility or an MBO. 

Photographs or interviews of participants that execute this authorization form may be produced, 

duplicated, published, used and/or disclosed in any other manner by CHI, one of its MBOs, and/or 

either of its subsidiaries, affiliates, providers or any other individuals or entities designated by such 

parties. 

This form has an optional provision to use in situations where compensation is made to 

participants. If compensation is provided, add the following provision as a new paragraph 

above the signature lines: 

For consideration in the amount of $__________________ _______________________ 

(Amount) (Insert initials of participant) 

If compensation is provided, you will need to replace the second to last paragraph of the 

authorization form with the new paragraph below. 

In addition, I waive all rights to or conditions on the use and/or disclosure of these photographs and/or interview 

material that I may have pursuant to this authorization and for the consideration provided, I further waive any claim 

for payment or royalties related to the production, duplication, publication or other use and/or disclosure of such by 

CHI, its subsidiaries, affiliates, or any other party involved in the specified use and/or disclosure, now or in the future. 

THIS IS A MODEL FORM; HOWEVER, THERE MAY BE ADDITIONAL STATE- 

SPECIFIC REQUIREMENTS FOR SUCH AUTHORIZATIONS, HEALTH 

INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (“HIPAA”) INCLUDING 

PRE-EMPTION OR MORE STRINGENT STATE LAWS, WHICH MAY 

NECESSITATE REVISION OR FURTHER CUSTOMIZATION OF THE ATTACHED 

FORM PRIOR TO ITS’ USE. 

For questions regarding use or applicability of this authorization, please call: 

� Terri Karsten, Associate Counsel, Provider Operations (859) 594-3008; or 

� Lauren Walker, Manager, Communications Services (859) 594-3111. 

REMINDER: This form should be reproduced on CHI letterhead. 

(This form was updated January 2006 and is HIPAA compliant as of this date for federal law 

purposes.) 

15

(Use on CHI Letterhead) 

CATHOLIC HEALTH INITIATIVES AUTHORIZATION 

TO BE PHOTOGRAPHED AND/OR INTERVIEWED 

Name of Participant: __________________________ 

I hereby voluntarily authorize Catholic Health Initiatives (“CHI”), and/or its subsidiaries, affiliates, 

agents, contractors, providers, or employees to interview and/or take photographs of me. I 

understand that the term photograph may include, but not be limited to, videotape, videodisc, digital 

image and any other mechanical means of recording or producing visual images (hereinafter referred 

to as “photographs”). I also understand the interview may involve, but not be limited to, audio tape, 

or other recording device, written recording or other mechanical means or medium to preserve the 

discussions (hereinafter referred to as “interview material”). 

I understand and agree that the photographs and/or interview material may also be used and/or 

disclosed for any and all other purposes deemed appropriate by CHI, and/or its subsidiaries and 

affiliate organizations. Such purposes may include, but not be limited to education, treatment, public 

relations, advertising, communication materials, promotional, and marketing publications (including 

postings on a organization’s website), and/or fundraising activities. 

I understand that I may refuse to sign this authorization, that there is no obligation to participate 

and that there will not be any condition on the treatment, payment, enrollment in any health plan, or 

eligibility for benefits based on my providing authorization for use and/or disclosure of my 

photographs or interview material. 

I agree to hold CHI harmless, and its subsidiaries, affiliates/facilities, agents, officers, contractors, 

providers, directors, and employees, or other third parties designated by these entities or individuals 

that are involved in the production, duplication, publication, or any other use and/or disclosure of 

the photographs and/or interview material for any damages or losses incurred by such use and/or 

disclosure of the photographs and/or interview material. I also understand that the photographs 

and/or interview material used and/or disclosed pursuant to this authorization may be re-disclosed 

by a recipient and such cannot be controlled by any of the aforementioned parties. 

In addition, I waive all rights to or conditions on the use and/or disclosure of these photographs 

and/or interview material that I may have pursuant to this authorization and waive any claim for 

payment or royalties related to the production, duplication, publication, or other use and/or 

disclosure of the photographs and/or interview by CHI, its subsidiaries or affiliates, or any other 

party involved in any use and/or disclosure, now or in the future. 

I further understand and agree that these photographs and/or interview material may be used 

beyond the initial purpose and expiration date if any listed below for archival and/or historical 

purposes by CHI, its subsidiaries or affiliates. 

Expiration: 

This authorization will expire on __________________________________________ (insert date 

or check box below if it applies). 

When no further production, duplication, publication or reprint or any 

other use of the photographs and/or interview material is required by 

16

Facility, CHI and/or its subsidiaries or affiliates. 

Revocation: I understand that I may revoke this authorization at any time by notifying CHI in 

writing by sending a letter to Jerry Miller, Communications, Catholic Health Initiatives, 1999 

Broadway, Suite 2600, Denver, Colorado, 80202, or completing the Revocation of Authorization 

form. I understand that if I revoke this authorization, it will not affect any actions that CHI took 

before it received my revocation letter. For example, CHI cannot rescind disclosures it has already 

made, and may use my health information as necessary to bill and collect for services rendered. 

Name: _______________________________________________________ 

(Please print name of participant) 

Signature: ____________________________________ Date: ____________ 

Witness: ____________________________________ Date: ____________ 

Address: ______________________________________________________ 

______________________________________________________ 

(City/State/Zip) 

If the participant involved is under age 18 or unable to grant authorization, the parent, guardian or 

legal representative, as applicable, must provide authorization: 

I hereby certify that I am the parent, guardian, or legal representative of _____________________, 

named above. I do give my authorization without reservation to the foregoing. 

Name of parent, guardian, or legal representative ______________________________________ 

(Please print name of parent, guardian or legal representative) 

FOR INTERNAL USE ONLY 

Signature: ____________________________________ Date: ____________ 

Witness: _____________________________________ Date: ____________ 

Marketing: If CHI will receive compensation for the use and/or disclosure of the photographs or 

interview material, CHI must disclose this to the participant. 

When CHI is requesting authorization to use health information for its own use, the following 

section must be completed and a signed copy must be given to the individual. 

Staff Personnel: 

Received by: _____________________________________ Date: _________________ 

A signed copy was provided to the individual: YES NO 

17

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