Authorization

Patient Authorization to Be Photographed and/or Interviewed

Authorization: By signing below, I hereby authorize Boulder Community Health and its affiliated facilities, agents, contractors, providers or associates to interview and/or take photographs of me. I understand that the term photograph may include, but not be limited to, videotape, digital image and any other mechanical means of recording or producing visual images (hereinafter referred to as photographs). I also understand the interview session may involve, but not be limited to, audio tape, or other recording device, written recording or other mechanical means or medium to preserve the discussions (hereinafter referred to as interview material).

I understand and agree that the photographs and/or interview material may also be used and/or disclosed for any and all other purposes deemed appropriate by Boulder Community Health, and its affiliated facilities, agents, contractors, providers or associates. Such purposes may include, but not be limited to, education, treatment, internal marketing (for example, photo displays within the facility), public relations, social media, advertising, communication materials, promotional and marketing publications (including postings on an organization’s website), and/or fundraising activities. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment in any health plan, or eligibility for benefits. I understand that I may revoke this authorization at any time in writing by contacting the Marketing and Public Relations department.

I agree to hold Boulder Community Health, and its affiliates, agents, officers, contractors, providers, directors, and associates, or designated third parties who are involved in the production, duplication, publication or any other use and/or disclosure of the photographs, and/or interview material harmless for any damages incurred by such use and/or disclosure of the photographs and/or interview material. I also understand that the photographs and/or interview material used and/or disclosed pursuant to this authorization may be re-disclosed by a recipient and can no longer be protected by the aforementioned parties. In addition, I waive all rights to or conditions on the use and/or disclosure of these photographs and/or interview material that I may have pursuant to this authorization and for the consideration provided, I further waive any claim for payment or royalties related to the production, duplication, publication or other specified use and/or disclosure of such by Boulder Community Health and/or any affiliated facilities, or any other party involved in the specified use and/or disclosure, now or in the future.

Expiration: Without my express revocation, this authorization will automatically expire upon satisfaction of the need for disclosure, but in any event will expire 1 (one) year from the date hereof, unless specified here (insert date or check box below):