Share Your Story

By agreeing to this authorization, you hereby authorize photographs, motion pictures, video tapes or media interviews for Hillcrest HealthCare System (HHS) Marketing Communications department or its affiliated hospital(s) and entities, subject to the below listed conditions:

1. That the first name of the patient/person and/or the patient’s/person’s family may be used to identify the photographs, motion pictures, video tapes or subject of interviews.
2. That said photographs, motion pictures, video tapes or subject of interviews will or could be released to external recipients including media, publishers, persons of organizations within the medical industry, the general public and/or Social Media.
3. That all photographs, motion pictures, video tapes or interviews need not be shown to the undersigned prior to their publication and/or viewing.
4. That all prints and negatives of any type shall be the sole property of Hillcrest HealthCare System, its affiliated hospital(s) or the media. This designation is irrevocable.

WAIVER OF COMPENSATION
The undersigned has entered into this agreement in order to assist education, public relations and charitable goals and herby waives any right to compensation for such uses by reasons of the foregoing authorization. This waiver is irrevocable.

RELEASE OF LIABILITY
This authorization is expressly intended to release from all liability of any nature the operating physician, attending physician, consultants of any nature and all agents and other personnel employed at Hillcrest HealthCare System or its affiliated hospital(s) and entities with regard to the taking, publishing or viewing of the photographs, motion pictures, video tapes and/or interviews. This release is irrevocable.

I understand that I may revoke this Authorization at any time in writing except to the extent that action has already been taken by HHS or the media after I signed this Authorization. The waiver of compensation and release of liability cannot be revoked, WARNING: We have no control over any photographs, motion pictures, video tapes or interviews released to any person, firm or agency under this authorization and it is therefore possible that a release of photographs, motion pictures or video tapes may occur by such party - and will no longer be protected by federal law,

I UNDERSTAND THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE INFORMATION WHICH MAY BE CONSIDERED INFORMATION ABOUT COMMUNICABLE OR VENEREAL DISEASE WHICH MAY INCLUDE, BUT NOT BE LIMITED TO, DISEASES SUCH AS HEPATITIS, SYPHILIS, GONORRHEA, AND ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS). I UNDERSTAND THAT BY SIGNING THIS AUTHORIZATION, I AM CONSENTING TO DISCLOSURE OF SUCH INFORMATION.

NOTICE OF RIGHTS
Information in your medial records that you have or may have a communicable or venereal disease is made confidential by law and cannot be disclosed without your permission except in limited circumstances including disclosure to persons who have had risk exposures, disclosure pursuant to an Order of the Court or the Department of Health, disclosure among healthcare providers or for statistical or epidemiological purposes. When such information is disclosed, it cannot contain information from which you could be identified unless disclosure of that identifying information is authorized by you, by an Order of the Court or the Department of Health or by law.