I hereby give AdventHealth permission to use and share protected health information about the Subject to the general public for the purpose of sharing the Subject’s Likeness or the Subject’s Story in any medium (e.g., television broadcast, electronic or digital media, printed material, newsprint, brochures, all printed collateral, motion pictures and video). The specific protected health information used to tell the Subject’s Story will include and be in reference to the information referenced below.
I understand this permission may be cancelled at any time by writing to AdventHealth, 900 Hope Way, Altamonte Springs, FL 32714, Attn: Privacy Officer; but if I cancel this permission after AdventHealth has already created or produced Subject’s Likeness or Subject’s Story on social media, commercials or other publicly available mediums, AdventHealth will still be able to use and share my protected health information contained in the Subject’s Likeness and the Subject’s Story as permitted by this form prior to my cancellation. In other words, AdventHealth will not create or produce any new stories or projects using the Subject’s Likeness or the Subject’s Story.
I understand that by permitting this using and sharing of my protected health information, the general public is not required to keep my protected health information that is part of the Subject’s Likeness or the Subject’s Story private as required by the Federal privacy laws.
I understand that signing this form is completely voluntary and I am signing it under my own free will. I understand that AdventHealth will not condition treatment, payment, enrollment in any health plans or my eligibility for benefits if I decide not to sign this form.
I understand I will receive a signed copy of this form.
For purposes of this form, the term “AdventHealth” shall include all business entities, which are now or in the future owned or controlled or managed by AdventHealth.