|Consent for Photography/Videotaping/Interview|
(For Media, Public Relations, Marketing, and Educational Purposes)
I consent to the use of interviews, photographs, or videos of me or my family member(s), including images and information that may disclose my protected health information, for use, reproduction, and/or publication by Sentara Health and/or Optima Health Plan ("Sentara"), and authorize release and use by Sentara to other organizations or news outlets, including local, regional, national, and international print, broadcast, and internet media and other electronic media.
Check the box for either “I do” or “I do not” consent to use your name.
Type your name in the signature box and date to complete.
I understand and agree that my name and these images and interviews, including me or my family member’s name, image, likeness, and/or voice, may be used by news media or by Sentara for purposes of education, promotion, public relations, and/or marketing, and that they may appear in print, on television, in radio broadcasts, the internet or text messages. I understand that there is a possibility that I may be identifiable in these photographs, videos, or written/audio accounts, though my name will not be published unless I specifically agree below.
I agree to release and hold harmless Sentara, its trustees, agents, officers, and employees from any and all liability which may arise from the making of or use of these photographs, videos, or interviews, and, if specified, use of my name, and I will not request payment for the use of my image, likeness, or name. I hereby waive and release Sentara, its Trustees, officers and employees from liability for any claim that I or my family member may have based on rights of privacy, publicity, defamation, copyright or trademark infringement, disclosure of protected health information, or any other right based on Sentara’s use of any image, recording of me or my name.
I understand that signing this authorization is strictly voluntary and that I may revoke it at any time. However, I acknowledge that any interviews or images to which I consented prior to revocation may already be in the public domain and not retrievable. I also understand that any protected health information released by me under this consent will no longer be protected by federal or state privacy laws.