Authorization & Release for Photography/Audio/Videotaping/Broadcasting/Interviewing
As applicable and furtherdescribed below, I authorize Emerald City Therapies and its affiliates to photograph, audio record, videotape, broadcast and/or interview me or I agree to take part in radio or TV programs. Describe Interaction (i.e. context of interviews, event at which photos are to be taken, etc.) and nature of protected health information to be gathered about patient:
Pictures and videos taken during the social groups and related outings. Photos/videos maybe used on Emerald City Therapies’ website, Facebook, or Instagram accounts. They also may be used for publicity in local papers and/or on the website to publicize the groups and related activities.
I authorize Emerald City Therapies to 1.) identify by me by name in any photographs, video, and/or audio tapes, interviews, broadcasts and/or new stories generated for the permitted interaction; 2.) to use or disclose such materials (along with my name) for display in print, radio, TV, or internet or media or other forms of media for advertising, marketing, fundraising, promotional and educational purpose (“permitted use”); 3.) to use and disclose such materials as necessary to effectuate the permitted use (i.e. to employees of newspapers or radio stations.
I authorize Emerald City Therapies and its affiliates to copyright any photographs, videos, broadcasts, and/or interviews generated from the permitted interactions.
I understand that, to the extent the content of the permitted interaction contains my protected health information. This information is protected under the federal privacy laws and regulations and under the general laws of Texas and cannot be disclosed without my written consent except as otherwise specifically provided by law. I understand the person or entity that receives my protected health information (as applicable) is not a health care provider or a health plan covered by privacy regulations, the information described above may be re-disclosed and is no longer protected by those regulations. Therefore I release Emerald City Therapies from all liability arising from the disclosure of my health information. I understand this authorization with expired ten years from the date signed below. Prior to the expiration date, I understand I may revoke this authorization in writing:
Emerald City Therapies 102 YMCA Drive, Ste E Waxahachie, TX 75165.
I understand any previously disclosed information may not be subject to revocation request.
I understand that I may refuse to sign this authorization and my refusal to sign will not affect my ability to obtain treatment, payment, or my eligibility for benefits with Emerald City Therapies.
Emerald City Therapies has an OPEN PICTURE POLICY. Children participating in groups may have their pictures and/or videos taken. Pictures/videos may be used for training purposes, program development, marketing, and including but not limited to newspaper articles, television promotions, brochures, social media, and other vehicles such as annual reports, board meeting materials, grant and website materials.
Mon 8 am - 5 pm Tues 8 am - 5 pm Wed 8 am - 5 pm Thurs 8 am - 5 pm Fri 8 am - 5 pm