PATIENT CONSENT FORM AND WAIVER
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION AND/OR PUBLIC USE OF IMAGE (PHOTOGRAPH OR VIDEOTAPE) FOR MEDIA AND PUBLIC RELATIONS PURPOSES
I hereby give consent to Cancer Center of Kansas, P.A. (“CCK”) to take and use images (photographs or videotape) or sound recordings of me and/or the person named below for whom I am giving consent (the “Patient”), or to allow another external media source to do any of the same, and to disclose confidential patient information, which may include protected health information as protected under HIPAA federal privacy laws, about me and/or the Patient, except as specified below, to or in any public media, including radio, television, internet or print, or in CCK’s publication. I understand that the intended use of such images and confidential information may be for advertising, marketing, fundraising or promotional purposes of CCK.
I understand that confidential information to be disclosed may include information about my treatment or the Patient’s treatment at CCK obtained from interviews of the family, physicians or other CCK personnel, or from the Patient’s medical records, and I hereby waive the right to or interest in the confidentiality of this patient information or images taken and disclosed to the public, as contemplated in this release.
I acknowledge that this consent and authorization for release of confidential information is being made solely for the benefit of CCK and without any expectation of compensation or other benefit to the Patient or family of the Patient. To the extent that any benefit accrues or might accrue to CCK from the use of images or disclosure of information, I hereby and forever waive any interest in or claim to such benefits.
I hereby release and forever discharge CCK (including without limitation all corporate affiliates and officers, directors, shareholders, employees and agents) from any and all claims, liability, actions, suits, demands, costs, expenses or indebtedness arising out of, related to, or in any way connected with the use of images or disclosure of the confidential information and materials described herein, and I hereby waive all rights and interest in and to such information and materials.
I have been informed that once this information is disclosed it may no longer be protected by federal privacy regulations, including HIPAA federal privacy laws. I have been informed that this authorization is voluntary and is subject to revocation at any time, except to the extent that action has been taken in reliance thereon, by notifying CCK in writing at: Cancer Center of Kansas, P.A., Attn: Laura Monahan 818 N. Emporia, Ste 403, Wichita, Kansas 67214. I also understand that any revocation of this waiver shall in no way affect the care I receive at CCK.