Candle Form | Mountain Hospice

Authorization - Use or Disclose PHI - Testimonials, Photos, Social Media

Date:*

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birth Date:*

Last 4 Numbers Social Security #:*

With your permission and authorization, we may use your information in printed materials, on our website, on social media we create, and we may release it to the media. Please understand this may involve the use or disclosure of information protected by federal health privacy law that requires your authorization first. We will use or disclose only information you authorize. This form explains your authorization. Please use it to authorize Mountain Hospice to use or disclose your information.

Authorization
I authorize Mountain Hospice to use and disclose information described in Section 1 of this form to publish information, a testimonial or comment about my experience or care I have received. My authorization to use my information extends to any persons working on behalf of Mountain Hospice to create or maintain materials in any format that may include my information, testimonial or comment including but not limited to printed materials, websites and social media. I authorize Mountain Hospice to respond to any comment or testimonial I provide to the extent that its response does not use or disclose any protected health information other than the information described in this authorization.

1. Description of information to be used or disclosed*

For your convenience you may check one or more boxes describing information to be used or disclosed in your comment or testimonial.

my photograph
a comment I write
my story – written by or for me
my name
recording (video or audio) of me
my initials only
any other information described in the box below

Other information:*

2. Purpose
The purpose of this Authorization is to permit Mountain Hospice to use or disclose the information described in Section 1 for public relations and marketing purposes by publication in any medium it creates or is created on its behalf including but not limited to its website, social media, social media website, newsletters, printed materials and press releases. Mountain Hospice will not receive any payment or financial remuneration from anyone for use or disclosure of this information.

3. Expiration Date of this Authorization
This authorization shall be valid - unless I revoke it earlier in writing - for ten (10) years following the date of the authorization.

I understand
1. I may revoke this authorization at any time by giving Mountain Hospice notice of my revocation in writing. 2. My revocation of this authorization will not apply to information used or disclosed as permitted by this authorization before I give Mountain Hospice written notice of my revocation. 3. Mountain Hospice may not condition my treatment or payment, enrollment or eligibility for benefits on whether I sign this authorization. 4. Information disclosed as permitted by this authorization may be re-disclosed by persons who receive it and is no longer protected by federal health information privacy law. 5. I have a right to request and receive a copy of this authorization. 6. I will not receive any payment or financial remuneration for the information I am authorizing Mountain Hospice to use and disclose by this authorization.

I understand this Authorization to Use or Disclose Protected Health Information for Testimonials and Social Media, signed it voluntarily and received a copy.

Signature, Individual/Personal Representative:*

Name, Personal Representative (if any):

Personal Representative’s Authority to Act:

Candle Details

In Honor / In Memory:*

In Honor of
In Memory of

Name*

Choose a Candle:*

Candle Price*

Price:

Coupon

Total

$0.00

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