SEVEN OAKS WOMEN’S CENTER
HIPAA & MEDIA RELEASE AUTHORIZATION FORM
I hereby authorize Seven Oaks Women’s Center and its duly authorized employees or agents, to publish the following personal health information or story that contains my name or likeness.
This photo or story may contain information relating to the diagnosis, treatment, and health care services provided or to be provided to me and/or my spouse and child by Seven Oaks Women’s Center and identifies my name and/or my spouse and child’s name and other personally identifiable information. This information may be used in print media, on the radio, TV, the Seven Oaks Women’s Center website, blog and on the following social media platforms: Facebook, Twitter, Instagram, and YouTube.
I understand that any personal health information or other information released via the social media platform(s) above may be subject to redisclosure by such social media platform(s) and may no longer be protected by applicable Federal and State privacy laws.
I understand that I have a right to revoke this authorization by providing written notice to SOWC. However, this authorization may not be revoked if Seven Oaks Women’s Center, its employee’s, or agents have acted on this authorization prior to receiving my written notice.
I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to seek treatment with Seven Oaks Women’s Center, eligibility for benefits or enrollment or payment for or coverage of services.
Lastly, I understand I will not be compensated for the use of any images or my likeness that is used in any social media platforms. I also understand that Seven Oaks Women’s Center and it’ s duly authorized employees or agents are not liable to notify photographers/agencies of the use of these photos, and it is between myself and the photographer to discuss the distribution rights of any images.