Authorization to Use and Disclose
Images, Voice Recordings and/or Testimonials
Patient Name: Date of Birth:
Address: Phone Number:
1. I hereb
y authorize Meridian Health Pascack Valley Medical Center (“Provider”) to use and disclose the following
inform
ation about the individual listed above (“Patient”): (a) photographs, digital images and other visual r
ecordings that
contain Patient’
s image, likeness and/or other Patient identifiable health information, including, if applicable, images of
Patient taken before and after the receipt of services from Provider; (b) recordings of Patient’s
voice and other audio
recordings containing Pati
ent identifiable health information; (c) biographical information and other pr
otected health
inform
ation about Patient, including any information included in testimonials or reviews provided by Patient in oral,
written, video or other form; and (d) information indicating that Patient received medical services from
Provider and
describing such services and Patient’s diagnosis.
2. Provider may use and disclose the information described above in, and to create, marketing materials, publications,
websites, presentations, advertisements and any other distribution media, including using and disclosing Patient’s
information in print media, on the radio, TV, Provider’s website, blogs and social media platforms, such as Facebook,
Twitter, LinkedIn and YouTube. Any
person or entity who receives, encounters or views these items or accesses Provider’s
website, marketing materials or other media may obtain this information. The purpose of this use and/or disclosure is to
promote and provide publicity to Provider. Provider may contract with third parties to capture the image,
voice or other
inform
ation described above, and the information may be used and disclosed by these third parties consistent with this
authorization.
3. This authorization will remain in effect until revoked by Patient unless state law requires a shorter time period. This
authorization may be revoked at any time by sending a written notice to Provider at Meridian Health Pascack Valley
Medical Center, Attn: Privacy Officer. However, expiration and/or revocation will not effect on any uses or disclosures
already made by Provider in reliance on this authorization. For example, Patient’s information may continue to appear in
promotional materials created or released by Provider prior to receiving the revocation for so long as those materials are
distributed, disseminated or have not expired, and information may continue to be available on the internet, social medi
a
and other media for an indefinite time even when it is no longe
r included on Provider’s website or Provider’s othe
r
prom
otional materials. Once Patient’s information is used and/or disclosed pursuant to this authorization, it may be fu
rther
used or
disclosed by the recipient(s) and may not be protected by the HIPAA Privacy Rules (45 CFR Parts 160 and 164)
.
I understand t
hat I may refuse to sign this authorization and that Provider will not condition treatment of Patient on whether
I sign this authorization.
4.
Patient will receive no financial compensation for the use
of Patient image or other information as described in this
authorization. Provider will not receive financial remuneration (compensation) from third parties in exchange for the use
and disclosure of Patient’s information.
Signature:
Date: __________________________
Print nam
e:
If signed by
personal representative, describe relationship: _____________________________________
27331849.1
click to sign
signature
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