Media Consent/Authorization Form & Waiver
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH AND OTHER PERSONAL INFORMATION AND/OR PUBLIC USE OF IMAGE (PHOTOGRAPH OR TVIDEO) FOR MARKETING, PROMOTIONA, MEDIA, AND PUBLIC RELATIONS PURPOSES

I hereby give consent to Horizon Health Care, Inc. (hereinafter “Horizon”), and its affiliates and subsidiaries to take and use images (photographs or video) or sound recordings of me and/or the minor patient/person named below for whom I am giving consent (hereinafter the “Patient”). I have been told that this story, advertisement and/or image (photograph or video) may appear in the public media, including social media, print, internet and/or broadcast media. I have been told that this story, advertisement and/or image (photograph and/or videotape) may be used more than once for promotional purposes by Horizon Health Care, Inc. and its subsidiaries.

Information to be used or disclosed may include anything I am submitting today, unless otherwise noted.
PHI may be used in, or disclosed to or by, the following unless otherwise noted:
· News media or print networks and the public at large via Internet, social media, newspapers, print publications, TV, radio, billboard, letter, or any other marketing correspondence or forum.

Marketing purpose(s) regarding the use or disclosure of PHI:
I understand that the information to be disclosed may include protected health information about the Patient’s treatment at Horizon Health Care obtained from interviews of the family, patient, and Horizon personnel. I hereby waive the right to or interest in the confidentiality of this information or images taken and disclosed to the public, as contemplated in this release. I understand that the information disclosed pursuant to this release may be re-disclosed and is no longer protected by any federal or state privacy regulations.

· Horizon will not receive direct or indirect payment in exchange for the use of disclosure of my PHI, but could indirectly benefit financially from sharing my image or statement by an increase in the use of its facilities, services or products, or through a fundraising campaign.
· I also understand that Horizon will not pay me for the use of the information, images or videos to be used and disclosed.

Expiration of this Authorization:
This Authorization will expire six years from this date.

Revocation of Authorization:
I understand that I may revoke this authorization/consent prior to its expiration to prevent the additional release of information and/or any photography, movie, video, or audiotape.
· Revocation requests must be sent, in writing, to Horizon Health Care, Attention: Marketing Department, PO Box 99, Howard, SD 57349.
· My revocation shall not stop any use or disclosure made by Horizon prior to the date it received my written revocation request.
· Horizon may not be able to stop an advertising campaign prior to the end of the campaign. I should not complete an Authorization for this use and disclosure of my PHI, if I am concerned that I may not wish to participate for the full campaign.

This Authorization is not a condition to my receiving treatment at Horizon Health Care:
· I am not required to participate in marketing projects. My decision to participate or not in this will not change my full access to treatment and services at Horizon.
· I understand that I have a right to receive a copy of this signed Authorization.
· I have read and understand this Authorization and my questions have been answered.
· I certify that I am the patient listed above or the patient’s authorized representative.
· I hereby release Horizon and its affiliates, employees, agents, and contractors from any liability arising from the use or disclosure of Protected Health Information or images pursuant to this Authorization.