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Download Terms

Authorization for Use and Disclosure of Health Information

Authorization for Use and Disclosure of Protected Health Information For Marketing and/or Promotional Purposes

Facility Wesley Medical Center, LLC

Type of information to be released: Video images, photographic images, conversations, sounds, audiotapes, verbal and/or written testimonials and statements, including biographical information, of the individual identified above.

Purpose of Request To videotape, photograph and record audio of patients for the facility’s marketing purposes, including but not limited to production of recordings, brochures, advertisements, videos and similar image and sound capture for purposes of publication and/or distribution via all types of media.

Payments to Facility This marketing activity involves direct or indirect compensation/payment from a third party to the facility for this use of protected health information.

Persons Authorized to Receive Information I agree that the publication and distribution of the protected health information described herein may and likely will include distribution of such information to the general public via various methods, including all types of media outlets (e.g., TV, radio, newspaper, Internet) for the facility’s marketing purposes. I also understand that the facility may hire third parties to capture the image and/or voice of the individual identified above, and that my information will be used and disclosed by these third parties as instructed by the facility. Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records Release I understand that if any videotape, photograph or audiotape references drug and/or alcohol abuse, psychiatric care, sexually transmitted disease, Hepatitis B or C testing, and/or other sensitive information, I agree to its release.

Expiration & Right to Revoke Authorization Except to the extent that action has already been taken in reliance on this authorization, at any time I can revoke this authorization by submitting a notice in writing to the facility Privacy Officer at Wesley Medical Center. Unless revoked, this authorization will expire on the following date or event: Six months from the date of the electronic signature.

In the event that facility has relied on this authorization to create marketing and/or other promotional materials featuring my likeness (e.g., photographs or video), audiotapes of my voice, my name, my testimonial or recommendation and/or other information released pursuant to this authorization, I understand and agree that facility shall retain the right to use my likeness, voice, name, testimonial and/or other information until such time as all such marketing and/or promotional materials then in existence at the time of any revocation of this authorization are distributed, disseminated or expire. Any revocation of this authorization will become effective only after all marketing and/or promotional materials are distributed, disseminated or expire.

Re-disclosure I understand the information disclosed by this authorization may be subject to re-disclosure by anyone receiving it, and the information disclosed will no longer be protected by the Health Insurance Portability and Accountability Act of 1996. The facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Signature of Patient or Personal Representative Who May Request Disclosure I understand that facility may not condition treatment, payment, enrollment, or eligibility for benefits for the individual identified above on whether I sign this authorization form. I may inspect or copy the protected health information to be used or disclosed. I authorize the facility to use and disclose the protected health information specified above for the purposes set forth above.

Signature/Date: acknowledged and agreed to electronically.


I agree to the above terms of the Authorization for Use and Disclosure of Health Information.

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Consent For Use and Disclosure of Image

Consent For Use And Disclosure Of Image, Voice And/or Written Testimonials

For good and valuable consideration, receipt of which is hereby acknowledged, I authorize Wesley Medical Center, LLC d/b/a Wesley Medical Center ("Wesley")and its respective parents, affiliates, subsidiaries, licensees, successors, and assigns to use the submitted photograph of me/my child including the right to publish my/my child's first name and birth date (collectively, the "Materials"). I understand that for purposes of this consent, the terms "image" and "photograph" encompass still photographs, digital images and any other method to reproduce or edit my/my child's likeness or image now known or hereafter developed.

Wesley shall be the owner of the submitted photograph with the right, throughout the world, an unlimited number of times in perpetuity, to copyright, to use, to publish, and to license others to use in any manner, including on the Internet, all or any portion thereof or of a reproduction thereof, free of any payment, royalty, or other compensation of any kind to me. I expressly understand and agree that the Materials and all results and proceeds derived therefrom, shall be the sole and absolute property of Wesley for any and all purposes whatsoever in perpetuity, free and clear of all claims whatsoever by me and/or on my behalf. I further represent that any statements made by me during my/my child's appearance or in the Materials are true to the best of my knowledge and that neither they nor my/my child's appearance will violate or infringe upon the rights of any third party. I hereby represent and warrant that I have not given any other person, entity or firm the exclusive right to use my/my child's name, likeness, voice or photograph, and that by signing this document I am not in breach of any other agreement to which I am a party.

I hereby waive any right of inspection or approval of the Materials and my appearance in such Materials and the uses to which such Materials may be put. I agree that the Materials may be edited in the sole discretion of Wesley and that Wesley is under no obligation to use the Materials. I acknowledge that Wesley will rely on this permission potentially at substantial cost to Wesley and hereby agree not to assert any claim of any nature whatsoever against anyone relating to the exercise of the permissions granted hereunder.

I hereby acknowledge that I am solely responsible for any statements made by me during the recording of my voice and/or likeness as described above, which statements shall consist solely of my opinions and do not necessarily represent those of Wesley, which is not responsible for the content of such statements.

I hereby acknowledge that neither Wesley nor any of its agents or employees have made any representations or warranties of any kind with respect to any medical or other advice or information that I may receive in connection with my/my child's appearance and that I have not relied on any such representations or warranties in agreeing to participate in the recording of my voice and/or likeness as described above or in the execution of this Consent for Use and Disclosure of Image, Voice and/or Written Testimonials (the "Consent").

I am signing this Consent as my voluntary act and deed, having read it in its entirety and understanding the contents thereof to my satisfaction, and I acknowledge that it is binding upon me, my legal representatives, heirs and assigns. I understand that this Consent will be signed contemporaneously with the form entitled Authorization for Use and Disclosure of Protected Health Information for Marketing and Promotional Purposes (the "Authorization"), and I agree that in the event of conflict between the two documents, the terms of the Authorization shall govern.


I agree to the above terms of the Consent For Use And Disclosure Of Image, Voice And/or Written Testimonials.

Please type your full name in the box below as acceptance of the terms above.