Patient Testimonial, Video, Photo, Audio Release Consent

Purpose of Consent: By signing this form, you are hereby consenting to allow Muskingum Valley Health Centers (MVHC) to use and disclose your testimonial, audio, photos and/or videos and you acknowledge that they may be distributed to the public.

Right to Revoke: You have the right to revoke this Release at any time by providing written notice of your revocation and submitting it to the Contact Person listed below.  Please understand that revocation of this release will not affect any action MVHC has taken in reliance on this release before your revocation. 

Consent to Release
I hereby authorize Muskingum Valley Health Centers (MVHC) and staff to use my testimonials, photos, videos, and audio and any information contained herein in its media/public relations efforts.  I understand and approve this disclosure of the testimonial, photo, video and/or audio information to the media and other individuals and entities that may be involved in the media/public relations efforts of Muskingum Valley Health Centers. 

 I understand that I am providing the testimonial, photo, video, or audio information to MVHC and that my treating healthcare provider will not be providing any protected information to the media or the public, including private health information in my medical records, the confidentiality of which may be protected by federal and state statues and regulations, including the Health Information Portability and Accountability Act (HIPAA). 

- I waive the right of prior approval and hereby release MVHC from any and all claims for damages of any kind based on the use of my testimonial, picture, video, audio or information in the testimonial. 

- MVHC has the sole discretion regarding which media to use and how to use them. 

- I understand that MVHC will not pay or provide compensation of any kind for the use of my testimonial and other media.

- I understand and agree that by signing this release I am waiving my rights to the media and they will become property of MVHC.  Thus, I authorize MVHC to copyright my material containing my image and audio in its own name or in any others name, and to use and distribute such material in any manner it desires for its public relations and marketing purposes. 

- I authorize MVHC to use my name in conjunction with an image

- I authorize MVHC to modify or alter the media.

- I understand that once the media described in this release form are released, they will not be subject to any privacy protection. 

 

Required Specific Release (This must be completed)

 This authorization for release of records may include the release of the following specially protected information unless specifically excluded.  

By signing below, I agree and acknowledge that I have read and understood the above Release and agree to all terms described.  I am of legal age and freely sign this Consent to Release my Patient Testimonial and other media I provided to the staff of MVHC.  I, on behalf of myself, my heirs, executors, administrators, successors, assigns, and any other person or entity claiming by or on my behalf, agree to waive all claims and causes of action against MVHC and its past, present and future officers, directors, members, agents, representatives, partners, affiliates, attorneys, subsidiaries, predecessors, successors and assign related to m, arising out of, or in connection with the use and/or disclosure of any media and/or my name in conjunction with any such image for purpose of public relations and/or marketing. 

For questions or concerns about this form or to revoke authorization please contact MVHC’s Privacy officer:

Jared Sheppard
716 Adair Ave.
Zanesville, OH 43701
(740) 891-9082