I hereby consent to the release of the health condition/status of: Patient Name (First, M.I., Last) to representatives of the media for publication, display or broadcast (print, web, digital display and all other forms of media).

I   First Name   Last Name have authorized the release of my name or the patient whom I am responsible for making decisions.

I hereby release KPC Health, its affiliates, employees, representatives and agents from any and all claims that may arise from the release of the information approved. I acknowledge that KPC Health has no control over the use of the information released. I direct KPC Health to release medical information regarding myself, my family member who I represent, and/or my minor child for the purposes of all media inquiries. The following information can be released and/or discussed:   List of Information   

I acknowledge that I have read this consent form in its entirety, or it has been read (or translated) to me, and I have had the opportunity to ask questions about it and understand it.