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Patient Release Form

Authorization for Use and Disclosure of Protected Health Information and Consent for the Use and Disclosure of Images, Voice and/or Written Testimonials

Vail Health sometimes asks patients to share experiences and information about their treatment at Vail Health Hospital or Vail Health Clinics. Similarly, some patients work with and permit third party media to publicly tell their medical stories. Sharing your story can help others learn more about Vail Health and can help Vail Health promote its mission of service.

Vail Health respects the privacy of our patients and we strive to ensure that your medical information is kept confidential and released only in accordance with your authorization and legal and regulatory guidelines. We are requesting your authorization to use your personal health information, so that we and your third party media company can share your story and Vail Health experience. Your consent will allow us to take and use testimonial and voice/video/photographic material of you in various communication formats, for educational, promotional, advertising or other purposes. Communication formats include, but are not limited to, internal and external communications, medical and general interest publications, medical and patient education information, and distribution by third party media companies (e.g. NBC Universal and affiliates), and the distribution of such materials online, in print, and in news media.

To ensure that Vail Health is acting in accordance with your wishes, and using your personal health information with your authorization, we ask you to complete and sign this authorization.

Authorization for Use and Disclosure of Health Information

I give my authorization for Vail Health, and any third party media companies I am working with, to use my or my child’s name and share details of my or his/her treatment and experience as a Vail Health patient in communications produced by or on behalf of Vail Health, and I consent to Vail Health and the authorized third party media companies taking and making use of my and/or my child’s written/audio/video/photographic images in publications, produced by or on behalf of Vail Health. This authorization extends to electronic versions on the Vail Health websites and other social media, internet/electronic, TV and radio applications as well as printed, filmed, and taped versions.

I understand that I may revoke or withdraw this authorization at any time to prohibit future use of my information. To do so, I must send written notice to the Vail Health Privacy Officer at PO Box 40,000, Vail, CO 81658. I understand that Vail Health, as well as other persons or entities, may retain copies of any such publications and that any revocation of this authorization will only extend to the versions of the information within Vail Health’s control that have not been previously published. Any such revocation will not apply to third party media companies. If not revoked/withdrawn by me, this authorization expires fifty (50) years from the date that I sign it. Any revocation of this Authorization will become effective only after all marketing and/or promotional materials are distributed, disseminated or expire.

Even though I may revoke or withdraw this authorization, I understand that my protected health information may exist forever in either a recorded, printed, and/or electronic format or other format that may develop over time and that once it is published or disclosed in any form, it may continue to be used. I understand that information about me or my child used or disclosed pursuant to this authorization may be subject to re-disclosure and will no longer be protected by the federal regulations protecting the privacy of an individual’s health information under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable federal and state law.

I understand that I am a volunteer and that I will not be compensated or paid for granting Vail Health the right to use my testimonials, images and/or voice.

If my medical records or any videotape, photograph, audiotape or other communication medium references drug and/or alcohol abuse, psychiatric care, sexually transmitted disease, Hepatitis B or C testing, and or other sensitive information, I specifically authorize its use as noted directly below:

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I understand that I am not required to sign this authorization and that Vail Health will not condition treatment, payment, enrollment or eligibility for benefits on the signing of this form

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If Signed by Parent/Guardian/Personal Representative:

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