Issue link: https://blog.providence.org/i/1545454
AUTHORIZATION TO INTERVIEW, PHOTOGRAPH, AUDIO/VIDEO RECORD 1. I authorize Providence Health & Services and its affiliated entities (collectively, "Providence"), including those physicians and providers who provide professional services to me as members of their medical staff (each a "Provider") to interview, photograph, audio/video record me and to use the interview(s), photograph(s), or audio/video recording(s) (collectively, "content") as described below regarding: Name of patient or individual - please print Address: City: State: Zip: Phone number: E-mail address: 2. Initial all that apply Display/Bulletin Board Internet (including on any Providence or Provider hosted or controlled website) Social media Magazine Medical education presentation Journal Event material Newspaper Radio Live Broadcast/Presentation Brochure Television/Video Providence internal use Other specific use: Indicate specific use: 3. I __do/__do not authorize members of my care team to be interviewed or otherwise discuss details of my care. 4. I understand that the content used or disclosed may be used or disclosed for the purposes that I have consented to above and may include, but not be limited to, my name and/or personal testimonial; my image, likeness or voice; and personal and/or health information. 5. I understand that the content used or disclosed pursuant to this authorization is not covered by federal privacy regulations, and that any health information contained in such content that is disclosed pursuant to this authorization may be re-disclosed and is no longer protected under federal law. 6. I understand that I do not need to sign this authorization. Refusal to sign the authorization will not adversely affect my ability to receive health care services or payment or eligibility for benefits. 7. I understand that I have the right to request that filming/interviewing/recording be stopped at any time. 8. I understand that I have a right to receive a copy of this form and that Providence will provide me (or my personal representative) a copy of this signed authorization. 9. This authorization expires on: ____________________________________________, or one (1) year from the date it is signed, whichever comes first. 10. I understand that I have the right to revoke this authorization at any time until the content is published or related to future publication by making a request to Providence in writing. After publication, it is generally not feasible for Providence to remove or terminate use of content. I understand that I may request in writing that Providence remove or terminate use of content published pursuant to this authorization, and that Providence will, if feasible, take reasonable steps to remove or terminate use of such content. I understand that, where feasible, it will take Providence a reasonable period of time to accomplish such removal or termination of use and that will not be immediate. To request revocation of this authorization or removal or termination of content use, please send a written statement (including your full name, address, phone number and date of authorization) identifying your intended request to: Attn: Providence Communication Operations, 1801 Lind Ave. SW, Renton, WA 98057 or emailing Communications@providence.org. You may call 1-888-294-8455 with any questions. Individual or Personal Representative Name (please print): Signature: Description of personal representative's authority: Date: PATIENT LABEL Form 1846 rev. 09-2024 For Official Providence Use Only. A copy of the form will be available to the patient and/or the patient's personal representative. Name and title of Providence employee arranging: Description of interview, photograph and/or video: Program funding grant ✔ ✔ ✔ ✔