Project Rollway Media Consent Form

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All Project Rollway models must complete this media consent form. If the model is under 18, their parent or legal guardian acting as their representative must complete it for them.

Who is this media consent for (the person being pictured, interviewed, video, etc.)?

Please fill out, review, and submit the following information. The individual participating in the “Media Content” (defined below) must be submitted on the form.

First Name

Last Name

Event Name

Notes:

I authorize Shepherd Center, Inc. (the "Hospital") and its employees, marketing and

publicity agencies, independent contractors, agents, and consultants (collectively,

"Shepherd"), and the mass media to photograph, film, videotape, interview, and/or

otherwise identify me (the “Media Content”). All photographs, interviews, and

recordings are collectively called the “Media Content.” I also

authorize the above-referenced parties to disclose such Media Content and basic

biographies such as my name, for marketing and internal training purposes.

I further understand that concerning the Media Content, Shepherd does not expect to receive any direct or indirect compensation for these uses.

I may revoke this Authorization in writing at any time, except to the extent we have already relied on it in obtaining or disclosing such information, by sending the revocation by First Class Mail to Shepherd Center, Inc., Attn: Privacy Officer, 2020 Peachtree Road, NW, Atlanta, Georgia 30309. The revocation will be effective when the Shepherd Center Privacy Officer receives it.

Shepherd and members of the mass media may use the Media Content in broadcast, print, or electronic (e.g., television, radio, newspaper, magazine); Hospital publications (e.g., magazines, newsletters, advertisements, brochures); and internet websites.

Shepherd cannot control the use or misuse of the Media Content after publication on the website or in other published media.

Recipients of Media Content may redisclose this information to others. If redisclosed, Federal and State privacy laws may no longer protect the information.

Specific photographs or other materials that identify me cannot be used in published media without my consent, which I hereby give freely via this written Authorization.

I am entitled to receive or retain a copy of this Authorization

This Authorization and consent to public disclosure of the Media Content is being made solely for the benefit of Shepherd and without any expectation that I or my family will receive any compensation, remuneration, or other benefit.

I release and hereby agree to hold Shepherd free and harmless from any

liability arising out of the current, future, or prior use, publication, and transmission

of the Media Content.

By checking "yes" and clicking submit, I agree to consent.

Yes, I agree to the media consent form.

Please fill out, review, and submit the following patient information. The patient, a patient representative, or a Shepherd Center employee must submit the form.

Patient First Name

Patient Last Name

Patient Date of Birth

Which option best represents you:

Name of Representative

Relationship to Patient

Representative Email

Name of Employee

Please Choose One:

The patient is unable to sign Consent & Release Agreement but gives verbal approval for the use or disclosure of photographs, films, videos, interviews, and other information as described in this Consent & Release Agreement. The patient is unable to sign Consent & Release Agreement, but his or her authorized personal Representative or next of kin, as applicable, approves the use or disclosure of photographs, films, videos, interviews, and other information as described in this Consent & Release Agreement. The patient or the patient's representative has signed an original copy of the Consent & Release Agreement and kept it for their records. The patient or representative gives verbal approval for using or disclosing photographs, films, videos, interviews, and other information as described in this Consent & Release Agreement. This is a version of the form for Shepherd Center's records.

Do you want to add additional family & friends of the patient to this media consent?

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

Event Name:

Notes:

I authorize Shepherd Center, Inc. (the "Hospital") and its employees, marketing and publicity agencies, independent contractors, agents, and consultants (collectively, "Shepherd"), and the mass media to photograph, film, videotape, and/or interview, and/or identify me. I also authorize the above-referenced parties to disclose such images and confidential information, including protected health information ("PHI"), such as my status as a current or former patient of the Hospital and descriptions of the treatment that I recieve(d), for marketing and internal training purposes.

I further understand that:

Shepherd does not expect to receive any direct or indirect compensation for these uses.
I do not have to sign this Authorization and Release Agreement ("Authorization") to access treatment, medical care, or other services from the Hospital and staff.
Hospital will not disclose my medical records pursuant to this Authorization, although I acknowledge that the Hospital will still have the right to disclose my medical records as otherwise permitted by HIPPA.
I may revoke this Authorization in writing at any time, except to the extent we have already relied on it in obtaining or disclosing such information, by sending the revocation by First Class Mail to: Shepherd Center, Inc., Attn: Privacy Officer, 2020 Peachtree Road, NW, Atlanta, Georgia 30309. The revocation will be effective when the Shepherd Center Privacy Officer receives it.
Shepherd, and members of the mass media, may use photographs, videos and other depictions or descriptions of me, my medical condition and my treatment information in broadcast, print or electronic (e.g., television, radio, newspaper, magazine); Hospital publications (e.g., magazines, newsletters, advertisements, brochures); and internet websites.
Shepherd does not and cannot control the use or misuse of the images and other information after publication on the website or in other published media.
Recipients of these communications may redisclose this information to others. If redisclosed, the information will no longer be protected by HIPAA and other Federal and State privacy laws.
Shepherd and the mass media may use photographs, videos or other depictions of my family and friends in the same manner.
Specific photographs or other materials that individually identify me cannot be used in published media without my consent, which I hereby give freely, and this written Authorization.
The Hospital cannot condition my access to treatment, admission, or medical services upon signing this Authorization.
I am entitled to receive or retain a copy of this Authorization
This Authorization and consent to public disclosure of confidential information, including PHI, and waiver of confidentiality in this Authorization is being made solely for the benefit of Shepherd and without any expectation that I or my family will receive any compensation, remuneration, or other benefit.

I release and hereby agree to hold Shepherd free and harmless from any and all liability arising out of the current, future or prior use, publication and transmission of the photography, filming, videotaping and/or interview information, including information regarding my medical condition or treatment.

By checking "yes" and clicking submit I agree to consent.

Yes, I agree to consent to the HIPAA Authorization and Release Agreement.

Yes, I'm the patient's representative and agree to consent on behalf of the patient.

Yes, I'm a Shepherd Center employee and agree to consent on behalf of the patient.

Contact Information