Providing your consent to participate in marketing

Informed Consent 

I consent and authorize OrthoIndy, OrthoIndy Hospital and affiliates (“Providers”), including their employees and representatives, to:

• Take or arrange for photographs, videotapes, audiotapes, testimonial and descriptions of myself, my health information and other mediums of protected health Information (collectively, the “Media”) to be made of me, my child or person for whom I am legal guardian.
• Digitize, modify, alter, edit, display, reproduce, license and release the Media, including my image, likeness, voice, appearance, and right of publicity to other individuals and entities for internal and external educational, promotional, marketing, advertising, and entertainment purposes. These purposes include, but are not limited to, lectures, symposiums, medical journals, news releases, printed materials, publicity, publications, and advertising that may be distributed in ways that include, but are not limited to, radio, television, mail, newspapers, magazines, email, websites and social media.
• This marketing activity DOES NOT involve compensation/payment from a third party to the Providers for this use of protected health information.

Further, I understand that signing this consent and authorization is voluntary and I am not required to sign this document in order to receive, or continue to receive, care or treatment from Providers.

By signing this consent and authorization, I agree that:

• The Media, including all copyrights and other intellectual property therein, will be the property of the Providers.
• Neither I nor anyone else will receive any compensation, including royalties, for the Media even if used by the Providers and released to other individuals and entities, including to social media.
• My identity and health information including, but not limited to, my health condition can be revealed by Providers in the Providers’ use and release of the Media.
• Once the Providers release the Media, the Providers do not have any control over the Media and it is subject to further re-disclosure.
• I waive my right to review the Providers’ use of the Media and assign to the Providers my rights, title and interest in the Media.

This authorization is valid until the Media is no longer utilized by the Providers for the purposes stated herein unless revoked by me by providing written notice to: OrthoIndy, Attn: Compliance Officer, 8450 Northwest Boulevard, Indianapolis, IN 46278.

I understand that if I revoke my consent and authorization, the Providers cannot take back the Media from individuals and entities that have already received that information after relying on my consent and authorization and cannot stop the individual and entities that have already received the information from using it.

I have had enough time to discuss with the Providers the information on this form. I have had the chance to ask questions and my questions have been answered. I have read and understand the information. I understand that I may have a copy of this form after I sign it. I release the Providers and their employees and representatives from any and all liability, which may or could arise from the taking, arranging, use or release of the Media.