Consent for Media Coverage

Name of Patient/Subject*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email

Phone*

Consent for media use*

I do hereby give my permission for Newman Regional Health public relations officials, other designated hospital officials, or employees of local/regional media, to interview, photograph, audio record, video record, use my photograph or image, and use any verbal or electronic communication for the purposes indicated below.

Attach files (photos, videos, recordings, etc.)

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Max. file size: 100 MB.

My Consent:*

I authorize the use of the above person's name (or family's name) in connection with the above use(s).
I give permission for use of any quotation and comment made verbally or recorded regarding the features individual's medical case.
I understand:
This publicity will be seen by the public and I accept this visibility.
The photographs(s), and/or interview comment(s) will not be used for any other purpose than the one(s) indicated above without my additional written consent.
All photographs, recordings, notes and materials shall become the property of Newman Regional Health or the media involved.
I waive any right to inspect or approve the finished product, or any material 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 effect 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 the information and images I provide will not be used for treatment purposes and will not be kept as part of my medical records.
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.

I agree with the media consent policy

Signed*

Full Name of Patient/Subject

Electronic Signature

By clicking below I submit my authorization and consent

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