I agree to be interviewed, filmed, videotaped, recorded, and/or photographed and I give New Orleans Regional Physician Hospital Organization, L.L.C. d/b/a Peoples Health and its affiliates (“Peoples Health”), and any third party approved by Peoples Health (“Approved Third Party”), permission to use, publish and reproduce the following:
• my name, likeness and image;
• my performance, voice, any other indicators of my identity, biographical information; and
• any statements I make in the audio and/or video recordings, transcripts, and other materials that result from the interview or recording sessions which are referred to above (collectively called “Materials”).
Peoples Health and any Approved Third Party may use, publish and reproduce the Materials in any media (including those which may not yet have been developed) for as long as Peoples Health or any Approved Third Party requires for advertising, marketing, educational, commercial, and/or promotional purposes.
I confirm that:
• any statement I make in the Materials will be, to the best of my knowledge, an honest and accurate reflection of my personal opinions and beliefs and I will inform Peoples Health if at any point in future I believe that is not the case; • the Materials belong only to Peoples Health and by signing this document I am transferring to Peoples Health all my rights relating to the Materials;
• I will not have the right to approve how the Materials are used, published or reproduced and I will not bring a claim related to how the Materials are used, published or reproduced; and
• I am a legal adult in my state or, if I am a minor, my parent or legal guardian has signed this Release below.
This Release is a legally binding document and I confirm that I do not intend to take any legal action against Peoples Health regarding the use, publishing or reproduction of the Materials, as long as such use, publishing or reproduction is as described in this document. I hereby release, waive and discharge Peoples Health and its directors, officers, employees, and representatives from any liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness, disease or affliction, including my death (but excluding physical injury), that may result from or occur in connection with the activities contemplated herein.
I acknowledge that Peoples Health may obtain information about me (e.g., criminal history) from third party sources, and I authorize Peoples Health to obtain all such information.
This Release is governed by and interpreted in accordance with the laws of the State of Louisiana, without regard to its choice of law provisions.
I confirm that I have read this Release, I understand its contents, and I am voluntarily entering into it. For good and valuable consideration, the receipt and adequacy of which are hereby acknowledged, I sign this Release below to indicate my agreement to its terms and conditions.
I understand that the Materials (as that term is defined in the Release & Consent) include information that reveals my identity, the health plan in which I am enrolled, and/or can be used to identify me; and/or relates to my past, present or future physical or mental health or condition, the provision of health care to me, or the past, present or future payment for the provision of health care to me. This type of information is known as protected health information under the Health Insurance Portability and Accountability Act of 1996 and its regulations (“HIPAA”). By signing this Authorization, I authorize Peoples Health and its affiliates (“Peoples Health”), and any third party approved by Peoples Health, to use and disclose any of my PHI that is included in or is otherwise part of the Materials for advertising, marketing, educational, commercial, and/or promotional purposes.
• I voluntarily grant authorization to use my PHI as set forth in this document, and I understand that I may choose not to grant such authorization by not signing this form. If I choose not to sign this form, I understand that Peoples Health will not deny me treatment, payment for health care services, or enrollment or eligibility for health care benefits as a result.
• I have the right to revoke authorization to use and disclose my PHI by sending a written request to the attention of Peoples Health’s Privacy Officer at 3838 N. Causeway Blvd., Suite 2200, Metairie, LA 70002 or by email to privacy@peopleshealth.com. I understand that my decision to revoke authorization will not have any effect on PHI which was used or disclosed by Peoples Health or by someone authorized by Peoples Health before it received my written request. A copy of Peoples Health’s Notice of Privacy Practices is available upon request and at www.peopleshealth.com.
• I do not authorize Peoples Health to use or disclose any of my PHI which is not included in the Materials.
• I understand that my PHI which is included in or is otherwise part of the Materials will be used and publicly disclosed by Peoples Health for advertising, marketing, educational, commercial, and/or promotional purposes. I further understand that by authorizing Peoples Health to use and disclose my PHI for those purposes, my PHI may be subject to re-disclosure by unknown third parties and, therefore, no longer protected by HIPAA.
This grant of authorization will continue in effect until I revoke it as provided above or it is terminated or expires by operation of law.
I confirm that I have read this document, I understand its contents, and I am voluntarily entering into it. For good and valuable consideration, the receipt and adequacy of which are hereby acknowledged, I sign this document below to indicate my agreement to its terms and conditions.
