If you wish to authorize to be interviewed, photographed, audio-taped, videotaped and/or filmed by Blanchard Valley Health System associates or their selected media representatives please complete and submit the form below. If you have any questions please call BVHS Corporate PR & Marketing at 419.423.5551. Thank you!
Patient/Participant (First, Middle, Last) *
Patient/Participant's Birth Date *
Please read the following information before agreeing and signing below:
I authorize to be interviewed, photographed, audio-taped, videotaped, and/or filmed (collectively called “Materials”) by Blanchard Valley Health System or their selected media representatives (“Blanchard Valley Health System affiliates”). The Materials may be used for publication, broadcast, medical instruction, patient education, electronic transmission (including digital media), or any other use Blanchard Valley Health System deems appropriate.
The purpose of this disclosure is to allow Blanchard Valley Health System representatives to record Materials, and/or for Blanchard Valley Health System to disseminate health information to the general public. I also authorize Blanchard Valley Health System personnel, including provider(s), to be interviewed by Blanchard Valley Health System representatives and to discuss details of relevant medical conditions.
I agree that any Materials taken shall be the sole and exclusive property of Blanchard Valley Health System or media representatives, and that they may use the Materials in any manner they wish, including dissemination to the general public via any media. I also understand that my name and/or identity may also be used for these purposes.
I release Blanchard Valley Health System, its employees, and representatives from any and all liabilities which may arise from the use of Materials. Blanchard Valley Health System will not condition treatment on whether I sign this authorization.
Furthermore, I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal and state law. Blanchard Valley Health System has the right to edit, modify and alter my image, likeness, statements, and recorded performance for use in the Materials.
I agree that the Materials will not be submitted to me for approval and that Blanchard Valley Health System will be without liability to me or others for the authorized use(s) of my image, likeness, statements, or recorded performance. I waive any right to inspect or approve the finished product, including written copy that may be created in connection with Blanchard Valley Health System’s use and license rights herein.
I understand I will not be paid or receive any royalties. This agreement will be binding upon my survivors, heirs, descendants, administrators, executors, and all others who have or may have a legal claim or rights by virtue of my agreeing to this Release and License.
I understand that this authorization may be revoked at any time except to the extent action has been taken in reliance upon it. Furthermore, I understand that this authorization will remain in effect unless specifically revoked by me. Revocation must be made in writing to Blanchard Valley Health System, PR & Marketing, 1900 South Main Street, Findlay, Ohio 45840.
Upon Blanchard Valley Health System’s receipt of this authorization, a digital copy can be provided if requested.
• If the patient/participant is 18 years of age or older, the patient/participant must select agree to this authorization form.
• If the patient/participant is 18 years of age or older and is incapable of signing, a legally authorized substitute may select agree to this authorization form.
ATTENTION: This is a legal document. Please read carefully. By selecting the check box yes, you agree that you understand and accept the terms listed in this form. Please list the full name (first, middle, last) of the person agreeing to the terms of this form: *
Please select below: *
If the patient/participant is not 18 years of age or older or is incapable of agreeing to the terms of this form, please complete the next two questions.
Please indicate your legal authority and include documentation of your relationship:
If the patient/participant is 17 years of age or younger, the patient’s/participant’s parent or legal guardian must agree and date the form,
unless an exception exists under state or federal law. Please indicate your relationship:
Printed name of person agreeing to the terms of this form (If not patient/participant) (first, middle, last)
Relationship to patient/participant
Mailing address (street, city, state, zip code) of person agreeing to the terms of this form *
Email of person agreeing to the terms of this form *
Completed digital consent forms retained in BVHS Corporate PR & Marketing, 419.423.5551.