Terms and Conditions

AUTHORIZATION STATEMENT(S):

I authorize Wellstar Health System to use and/or disclose my Protected Health Information (PHI) for Marketing and/or Media-related activities. I understand andacknowledge that (PHI) used or disclosed based on this Authorization may be subject to re-disclosure by the recipient and no longer protected by Federal Privacy Regulations & State Law.

I consent to the taking of photographs, recordings, and interviews of me, and authorize the publication of such photographs,         recordings, and interviews, and authorize the publication of information, statements or images of or about me, in order to assist with educational, promotional, public relations and charitable goals.

By signing below, I authorize and consent to permit Wellstar Health System, Inc. and its affiliates, and its and their respective successors and assigns (collectively,”Wellstar”) to use and publish, or permit other persons to use and publish, in any public manner Wellstar deems reasonably appropriate, my name, voice, photograph, likeness, quotes, stories and/or any other information, statements or images (collectively, “Personal Materials”) as follows:

• for any commercial or non-commercial purposes, including but not limited to, for marketing, advertising, fundraising, development, public relations, media relations, charitable, educational and scientific purposes; and

• in the form of print, audio, visual, social media and other online channels, including but not limited to, articles, blogs, web sites, brochures, pamphlets, newsletters,fliers, posters, advertisements, newspapers, film, live or taped television transmission, videotape, radio broadcast and internet publication, or any other medium now known or hereafter developed. I understand and agree that the photographs, recordings and/or publications may reveal the patient’s identity. The term “photograph” as used in this Authorization, shall mean motion picture or still photography in any format, as well as video or audio tape, videodisc and any other mechanical means of recording and reproducing images.

By signing this authorization and consent form, I hereby

waive any right to compensation for such uses, and I and my successors or assigns hereby hold Wellstar Health System, its administrators, directors, officers, employees or agents and related entities, and/or the attending physician and their successors and assigns harmless from and against any claim for any injury, and any compensation, resulting from the activities authorized by me in this consent form. Notwithstanding the foregoing, I understand Wellstar Health System may provide reasonable compensation for my time and inconvenience in participating in marketing and/or media related activities.

I hereby waive my right under relevant state laws to patient confidentiality with respect to the taking or publishing of any photograph, recording, interview, statement or image of me, as authorized in this consent form, with the exception of those limitations specifically identified by me in this consent form, if any, as follows:                                                     

request. I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my treatment, payment, enrollment in a health plan, or eligibility for healthcare benefits. I understand that I will be given a copy of this Authorization upon my signature.

I understand that Wellstar will not receive direct or indirect compensation regarding this disclosure for Marketing use.

I understand that I have the right to revoke this waiver, and to revoke my consent and authorization in this form, at any time, by notifying the Wellstar Health System in writing. However, I understand that my revocation will not apply to any actions taken based on this Authorization including PHI uses and disclosures that occurred prior to the receipt date of my revocation request, and/or advertising campaign content released prior to the receipt date of my revocation. I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my treatment, payment, enrollment in a health plan, or eligibility for health care benefits. I understand that I will be given a copy of this Authorization upon my signature.