Authorization & Media Release:
By submitting this form, I voluntarily authorize Grove Creek Medical Center, Bingham Healthcare, and their affiliated entities, employees, medical staff, contractors, successors, and assigns (“GCMC”) to use, reproduce, publish, distribute, and disclose my written testimonial, comments, likeness, image, voice, video, photographs, and any information I voluntarily provide for marketing, advertising, public relations, educational, promotional, fundraising, and related purposes in all media formats now known or developed in the future, including but not limited to websites, social media, digital advertising, print materials, television, streaming platforms, and email communications. I understand that my testimonial may include information related to my medical condition, treatment, or care, and by submitting it I authorize GCMC to publicly disclose this information. I acknowledge that once information is publicly disclosed, it may be re-disclosed by third parties and may no longer be protected under federal or state privacy laws, including HIPAA. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned upon signing this authorization. I understand that I will not receive compensation for the use of my testimonial, image, or likeness unless otherwise agreed in writing. I grant GCMC the right to edit, copy, modify, adapt, excerpt, caption, format, enhance for accessibility, or translate my submission for clarity, length, technical formatting, or publication purposes, provided the meaning is not materially altered. I understand that digital tools may be used to prepare submitted content for publication. This authorization will expire three (3) years from the date of submission unless I revoke it earlier in writing by contacting the Director of Marketing & PR, Grove Creek Medical Center, 98 Poplar Street, Blackfoot, ID 83221, and revocation will not affect any use made prior to receipt of my written request. I certify that I am 18 years of age or older, or that I am the parent or legal guardian of the individual named above and have legal authority to provide this authorization, and that I have read, understand, and voluntarily agree to these terms.