Media Authorization Terms
I hereby authorize Genesis HealthCare System to use and disclose information about me for the purposes of creating press releases, news stories, social media, photographs or video clips, website and/or publications, as well as stand-alone pictures/graphics in which I may appear and/or be heard, for use in internal Genesis publications and/or disclosure to external (non-Genesis) media.
The information about me may include my: name, treatment, age, duration of treatment, treatment plan, diagnoses, photographs, and information about my life and how I came to Genesis, my on-going treatment. The information may also be disclosed to external media in the form of press releases, stories, photographs or video clips. It may also be used for internal purposes or on the Genesis website or through Genesis’ own marketing or educational campaigns. Genesis will not receive any direct or indirect payment from or on behalf of any third party in exchange for the release of this information about me.
I understand the provision of health care treatment, payment for my health care and my health care benefits are not dependent on this authorization. I understand I am not required to sign this authorization; however the information will not be used or disclosed without authorization. I understand any information used or disclosed pursuant to this authorization may be subject to redisclosure.
I understand I have the right to revoke this authorization in writing, except to the extent information has already been released pursuant to this authorization at the time of the revocation. I can revoke this authorization by sending correspondence to the Corporate Integrity Department at Genesis HealthCare System.
I hereby release, disclose and agree to hold Genesis HealthCare System harmless from any liability that may arise from the release of information authorized above.
This authorization shall expire 10 years from date of signature.
If the patient is a minor or has a personal representative, I represent that I am the legal parent/guardian/personal representative of the Patient named above.