HIPAA Media Release For Patients

HIPAA Media Release For Patients

By submitting this form and sharing your story with us, you are agreeing to share your private health information. This form is your approval.

PATIENT NAME*

Please type in your first and last name.

Name of parent or guardian if the patient is under age 18

DO YOU WANT US TO CONTACT YOU?*

Select

WHAT MAY WE SHARE?

Please check all that apply (file upload link below):

Photograph(s) of me

Video and audio of me

A written story about me

I understand that any personal health information or other information released via a social media platform may be subject to re-sharing by such social media platform and may no longer be protected by applicable Federal and State Privacy Laws. I understand I have a right to revoke this authorization by providing written notice to GSOS. However, it may not be revoked entirely if GSOS, it’s employees or agents have already taken action on this authorization prior to receiving a written revocation. In that case GSOS will take down any content if and where possible and post no further content associated with this authorization. I understand that I have a right to a copy of this authorization. I fully understand that this authorization is voluntary and that I may not wish to sign this authorization. My refusal to sign will not affect my eligibility for benefits or payment for or coverage of services from GSOS.

Please check the box to authorize Golden State Orthopedics & Spine (GSOS), its duly authorized employees or agents, to publish your story.

I authorize publication of my story*

Please provide your mobile phone number*

Phone

Please provide your email address*

Today's date:

Send me a copy of my responses

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