*CONSENT to be in Columbus Community Hospital News Stories, Educational Materials or Promotions
I consent to be included in the following:
x Public news media (including print, such as newspapers/magazines, and/or broadcast, including TV/radio/Internet)
x Columbus Community Hospital marketing, public relations and educational materials
x To be interviewed
x To be Identified by name
EXCLUSIONS The undersigned agrees that Columbus Community Hospital may use and permit other persons to use the consented materials for purposes including, but not limited to, dissemination to hospital staff, physicians, health professionals and members of the public for educational and marketing purposes.
I understand that:
1. My participation is strictly voluntary. If I do not sign this form, my health care and the payment for my health care will not be affected.
2. I will receive no compensation for my participation.
3. This consent form will expire in 100 years and the materials may be retained indefinitely.
4. I have a right to withdraw my consent at any time by contacting the Columbus Community Hospital Marketing and Community Relations Department at 920-623-2200, until a reasonable time before the materials are used.
5. By signing this form, the personal health care information I relay to an outside source is no longer protected by state and federal privacy laws and may be re-disclosed by that source.
6. I understand that, in the instance of outside sources (such as the news media), Columbus Community Hospital is acting only as the intermediary, making it possible for the aforementioned source(s) to contact me. I agree to hold Columbus Community Hospital and its members, directors, officers and employees 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 have read Columbus Community Hospitals release terms and agree to them. I am the person listed above and am sharing my own story. I am the legal guardian of any minors mentioned or photographed in association with this “Power of Thanks". I hold the legal rights to all images I am submitting.