I understand that, in the instance of external sources (such as media outlets or law enforcement agents), Cookeville Regional Medical Center, Cookeville Regional Charitable Foundation and Cookeville Regional Medical Group are acting only as the intermediary, making it possible for the aforementioned source(s) to contact me.
As such, I relieve and hereby agree to hold Cookeville Regional Medical Center, Cookeville Regional Charitable Foundation and Cookeville Regional Medical Group free and harmless from any and all liability arising out of the use and/or release of information; interview; photograph/videotape/film; and subsequent publication or broadcast. I understand that the interview(s) or photo session(s) are being carried out upon my consent and authorization and so assume full responsibility.
I understand that:
- I may refuse to sign this authorization and that it is strictly voluntary.
- If I do not sign this form, my health care and the payment for my health care will not be affected.
- I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation.
- If the requester or receiver is not a health plan or health care provider, the released information may be redisclosed by the recipient and may no longer be protected by federal privacy regulations.
- I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it.
- I get a copy of this form after I sign it.
Patient consents to be:
Purpose of Use/Disclosure:
- Publication in newspaper(s), magazine(s) or other publications
- Social and digital media/website
- Broadcast by radio or television
- To document the progress of my care
- Cookeville Regional Medical Center, Cookeville Regional Charitable Foundation and Cookeville Regional Medical Group marketing and public relations materials/publications
Description of Protected Health Information to be Used or Disclosed:
- All Patient Identifying Information;
- Age/Date of Birth
- City of Residence
- Nature of Injuries/Illness