ShareThe Surgery Center at Doral / Badia Hand to Shoulder Center / OrthoNOWAuthorization to Disclose Health Information for Media and Advertising Purposes Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY PH Date MM slash DD slash YYYY Email(Required) 1. I authorize The Surgery Center at Doral (“SCD”), Badia Hand to Shoulder Center (“BHS”), and OrthoNOW (“ON”) and their duly authorized employees or agents to photograph, video, interview, or make electronic sound recordings of me, which may include my protected health information. Such photographs, films, sound recordings and or/interview content will disclose the fact that I am, or have been, a patient of SCD/BHS/ON and may contain other information about me, including private and protected health information, what I say in the interview, and facts that can be inferred from the photograph or film.2. I agree to grant SCD/BHS/ON the absolute right and permission to use and disclose, and to authorize others to use and disclose, my images or likeness, for any marketing or publicity purpose to the general public, including promotion of SCD/BHS/ON and publication on its website, brochures, presentations, social media, or commercials, in any manner, medium or form, whether now known or hereafter existing. I understand that I may be identifiable from the photographs, films, sound recordings and/or interview content I am authorizing SCD/BHS/ON to include me in.3. I understand that fellow(s) and student(s) observers may be present in the operating room for educational purposes.4. I understand that the photographic or electronic reproductions of me may be used from the date of this authorization until MM slash DD slash YYYY unless I revoke my consent prior to the expiration of such time.5. I may revoke this authorization at any time to the extent that use or disclosure of my protected health information has not already occurred prior to my request for revocation. I understand that, in order to revoke this authorization, I must notify SCD in writing at 3650 NW 82nd Avenue, Suite 101, Doral, FL 33166 and BHS in writing at 3650 NW 82nd Avenue, Suite 103, Doral, FL 33166.6. I understand that the photographs or images described above become the property of SCD/BHS/ON or its representatives. I agree to release SCD/BHS/ON from any and all liability and causes of action that may arise from the use of my image or likeness as described herein.7. I understand that this authorization is voluntary and that I may refuse to sign this authorization.8. I understand that SCD/BHS/ON will not condition my treatment, payment, enrollment, or eligibility for benefits on my signing this authorization.9. I understand that the protected health information used or disclosed as a result of this authorization may be re-disclosed by the person or entity receiving or viewing the information, and thus, the information would no longer be protected by federal and state privacy laws.10. This authorization is given without promise of compensation by any party to any other party.11. I understand that I must be provided with a copy of this signed authorization.Signature of Patient/Legal Representative(Required)Reset signatureSignature locked. Reset to sign againDate(Required) MM slash DD slash YYYY If Legal Representative, relationship to Patient Δ
