Media Consent, Authorization, and HIPAA Release

1. Authorization and Consent
I authorize TUBA1A Foundation ("Organization") to capture and use my:

• Photographs and video/audio recordings
• Written or recorded testimonials and personal story

For purposes of TUBA1A awareness, education, advocacy, fundraising, and promotion. TUBA1A Foundation will not share your private information to outside sources.

2. HIPAA Authorization (Use of Health Information)
I understand that my story may include protected health information (PHI) such as my diagnosis, treatment, or medical history. By signing this form, I:

• Authorize the Organization to use and disclose my health-related information for the purposes listed above
• Understand that once disclosed publicly, this information may no longer be protected under federal privacy laws such as the Health Insurance Portability and Accountability Act (HIPAA)
• Acknowledge that this authorization is voluntary

3. Scope of Use
Materials may be used in:

• Website and social media
• Email and newsletters
• Printed and digital publications
• Media outreach and press materials

I understand materials may be edited for clarity or length.

4. Compensation
I understand I will not receive compensation or royalties.

5. Right to Revoke
I may revoke this authorization at any time by contacting: tuba1afoundation@gmail.com
Revocation applies only to future use. Materials already published may not be fully withdrawn.

6. Release of Liability
I release TUBA1A Foundation and its representatives from any claims related to the use of these materials.

7. Acknowledgment of Reading and Understanding
I confirm that I have read, understand, and agree to the terms of this consent, authorization, and HIPAA release. I understand that refusal to sign does not affect access to services or support from the Foundation.