Saint Joseph Health System Corporate Identity and Graphic ...

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(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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