TGH and USF Patient Media Release

TGH & USF Patient Media Release

AUTHORIZATION AND RELEASE FOR USE AND DISCLOSURE OF PROTECTED INFORMATION FOR PUBLIC AFFAIRS, FUNDRAISING, & MARKETING ACTIVITIES
Patient Full Name*

First NameLast Name
Name of Legal Guardian/Parent (If applicable):

First NameLast Name
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Email Address*
example@example.com
Patient Phone Number*
Please enter a valid phone number.
Patient Date of Birth*

MonthDayYear
Date

TGH Patient Media Consent Form
The TGH Patient Media Consent Form:

AUTHORIZATION AND RELEASE FOR USE AND DISCLOSURE OF PROTECTED INFORMATION FOR PUBLIC AFFAIRS, FUNDRAISING, & MARKETING ACTIVITIES
I hereby authorize the taking and collecting of photographs, images, audio and/or video recordings of myself or my minor child, by Florida Health Sciences Center, Inc. d/b/a Tampa General Hospital (collectively "Hospital"), for the purpose of (initial all that apply):
Purpose(s) for Use and Disclosure (Select all that apply)*

Sharing with agents, contractors, or representatives of the news media and organizations authorized by TGH, as well as, on TGH’s social media platformsSharing with TGH for use in presentations, annual reports, and other documents produced by TGHSharing for educational purposes to be used by TGH and USF
I provide permission (initial one)*

Without restrictionsWith restrictions (please specify below)
If you selected 'With restrictions', please specify the restrictions here:
I am aware and agree that I will not receive any financial compensation relative to the taking or use of photographs, images, audio, or video recordings (“Media Materials”). I give permission to the Hospital to copyright, use and reuse the Media Materials.

I understand that I may refuse to participate in providing the Media Materials and the decision will in no way affect the care or treatment provided to me by the physicians or staff of the Hospital.

I understand that the Media Materials will not be considered part of my medical record and may be edited or destroyed at any time.

I understand that this Authorization will be in effect indefinitely unless I withdraw my consent in writing.

I hereby release and discharge Florida Health Sciences Center, Inc. d/b/a Tampa General Hospital, its affiliates and its employees, medical staff, directors, officers, agents, successors, assigns, heirs, executors and licensees, including the photographer or video photographer from any and all claims and demands arising out of or in connection with the use of the Media Materials in accordance with the terms of this Authorization, including but not limited to any claims for defamation, compensation, invasion of privacy, royalties, or infringement of copyrights or moral rights and any other recognizable claims, whether sounding in contract or tort.

I expressly consent to the use of my likeness, name, identity and accompanying verbalizations in the Media Materials.

I understand that the Media Materials may be republished over the internet and social media outlets or used by the hospital or news media in reporting a hospital or medical-related story, or for hospital-related advertising such as printed publications, web sites and television and radio broadcasts.
Patient or Guardian Signature*

Clear
Date of TGH Media Release Authorization*

MonthDayYear
Date

USF Patient Media Consent Form
USF Patient Media Consent Form

Patient Information Authorization for Release Through Stories, Video, Photography, Marketing and News Media
Date of USF Media Consent Agreement

MonthDayYear
Date
Story Topic
Faculty/Students Featured in Story
Authorization Statement
I authorize USF Health and its affiliates and agents to take photographs, produce videos, audio recordings, electronic files, or other types of media products that capture my name, voice, image to be released to members of the media, USF Health and organizations acting in official capacity of USF Health. Additionally, I authorize USF Health to use my information for the purpose of:

- News media (online, print, broadcast)
- Publications and/or promotional materials
- Closed circuit television programs
- Advertisements
- USF Health websites and social media
- Medical and/or educational training

Information to be disclosed includes:

- Photographic images/illustrations
- Video and audio of me and/or my voice
- Images from records (scans and/or X-rays)
- Information about my medical condition and/or prognosis
- Information about date(s), time(s) and type(s) of treatment received
- Other (please specify in the box below)
If other is applicable above, please specify:
Acknowledgment Statement
I acknowledge that once my information is disclosed, it will no longer be considered protected health information under HIPAA and may be redisclosed without my further consent for use by USF Health and approved uses by third parties. I further understand this authorization is voluntary, without compensation, and that I may refuse to sign this authorization. Refusal to sign will not affect my ability to obtain treatment or receive payment from my insurance company. Refusal will also not affect my eligibility for benefits. I understand that, by signing this form, I affirm that I have authority to sign this document, authorize the use of disclosure of protected health information, and declare there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.

This authorization will remain in effect indefinitely from the date below until such times as you notify USF Health of your intent to revoke this authorization. A written request to revoke this authorization can be sent to USF Health Communications and Marketing via email at healthcommunications@usf.edu. This revocation of this authorization will be effective the day the written request is received and acknowledged by the above mentioned. If I revoke the authorization, it will not have any effect on any actions taken by USF Health, or any third parties, prior to the processing of the revocation.
Are you the patient or a representative?*

PatientRepresentative (parent, guardian, or legal representative)
If your are not the patient, state your reason/relationship to the patient
Signature or Patient or Representative (e-signature)*

Clear
Date of Media Release Authorization

MonthDayYear
Date
Should be Empty:

TGH & USF Patient Media Release

The TGH Patient Media Consent Form:

USF Patient Media Consent Form