CONSENT FORM AND WAIVER (PATIENT & FAMILY)

AUTHORIZATIONFORRELEASEOFPROTECTED HEALTH AND OTHER PERSONALINFORMATIONAND/ORPUBLICUSEOFIMAGE(PHOTOGRAPHORVIDEO)FORMARKETING PROMOTION, MEDIAANDPUBLICRELATIONSPURPOSES

IherebygiveconsenttoChildren’sHealthcareofAtlantaInc.(hereinafter“Children’s”), its affiliates, media outlets, community organizations, and/or third parties providing service to Children’stotakeanduseimages(photographsorvideo)orsoundsrecordingsofmeand/ortheminorpatientorpersonnamedbelowforwhomIamgivingconsent (the “Patient”) ,and todisclose informationaboutmeand/orthePatient,toorinanypublicmedia,includingradio,television,internet, social media,orprint,orinaChildren’spublication.Iunderstandthattheintendeduseofsuchimagesandinformationisforadvertising,marketing,fundraisingorpromotionalpurposesofChildren’s.

Iunderstandthattheinformationtobedisclosedmayincludeprotected health informationaboutthePatient’s treatmentatChildren’sobtainedfrominterviewsofthefamily,physiciansandhospitalpersonnel,orfromthepatient’smedicalrecordsandIherebywaivetherighttoorinterestintheconfidentialityofthisinformationorimagestakenanddisclosedtothepublic,ascontemplatedinthisrelease. I understand that the information disclosed pursuant to this release may be re-disclosed and no is longer protected by the federal privacy regulations.

IacknowledgethatthisconsentandauthorizationforreleaseofconfidentialinformationisbeingmadesolelyforthebenefitofChildren’sandwithoutanyexpectationofcompensationorotherbenefittothePatientorthefamilythereof.While unlikely, Children’s may receive direct or indirect remuneration from a third party. TotheextentthatanybenefitaccruesormightaccruetoChildren’sfromtheuseofimagesordisclosureofinformation,Iherebyandforeverwaiveanyinterestinorclaimtosuchbenefits.

IherebyreleaseandforeverdischargeChildren’s(includingwithoutlimitationallcorporateaffiliatesandofficers,directors,trustees,employees,medicalstaffmembersandagents)fromanyandallclaims,liability,actions,suits,demands,costs,expensesorindebtednessarisingoutof,relatedto,orinanywayconnectedwiththeuseofimagesordisclosureoftheinformationandmaterialsdescribedherein,andIherebywaiveallrightsandinterestinandtosuchinformationandmaterials.

I understand that I may refuse to sign this authorization, that it is strictly voluntary and that my treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this release. Ihavebeeninformedthatthisauthorizationisvoluntaryandissubjecttorevocationatanytime,excepttotheextentthatactionhasbeentakeninreliancethereon,bynotifyingChildren’sinwritingat:.

Expiration:

  • Authorization is ongoing until Patient reaches age of majority (18yo) unless otherwise revoked.

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Date

Name of MinorPatientor Person (please print)DateofBirth ofMinor PatientorPerson

Name of Consenting Individual,Parentor GuardianRelationshipto MinorPatientor Person

Signature ofConsenting Individual,Parentor GuardianPhone Number

Zip code Email address