I give permission for use of any quotation and/or comment made by written, verbal or recorded method for the purpose of this review submission. I understand that my comments and identity may be seen by the public and I accept this visibility and grant Newman Regional Health permission to use and disclose said content and identity.
In the event that my quotation and/or comment may be used or disclosed, I waive any right to inspect or approve the use and distribution on any electronic platform, website, social media channel, broadcast or media share in which NRH may eventually use my images, recordings or comments.
I have the right to revoke this consent at any time, with reasonable notice prior to publication, by sending a written request to Business Development Director at 1201 West 12th Ave, Emporia, KS 66801. Such revocation shall not affect actions already taken and any distribution that has already taken place.
Information I disclose may be subject to re-disclosure by the recipient and may no longer be information protected by the Health Information Portability and Accountability Act (HIPPA).
That I have a right to request and receive a copy of this consent.
That this consent is granted on the date of submission of this form and will last until revoked in writing to the Business Development Director at 1201 West 12th Ave, Emporia, KS 66801.
I have read and understood the consent policy.
I have been given the opportunity to ask questions, which have been answered to my satisfaction - by contacting the Business Development Director at 1201 West 12th Ave, Emporia, KS 66801.