Client/Patient Consent to Release Personal Information
for Public Education, Promotional or Media Purposes

I, Enter your full name , agree to be interviewed, photographed and/or videotaped to share my personal story, artwork, and/or experiences with Preferred Family Healthcare. I authorize Preferred Family Healthcare to disclose my name, title, artwork, quotes, photograph, video and/or participation in Preferred Family Healthcare’s services, in the company’s publications and marketing material which will be distributed broadly in the community.

I understand my name, title, artwork, quotes, photograph, and/or video may be used for public education, marketing or multimedia purposes, such as printed materials, community presentations, displays, PFH social media sites or PFH websites. Said material shall be the sole property of Preferred Family Healthcare. I understand that the information I am authorizing be released may include first hand testimony regarding how PFH services, including substance abuse or mental illness services, have impacted my life and how PFH services helped.

I understand that use of my name, title, artwork, quote, photograph and/or video will disclose my involvement with PFH services, including Alcohol and Drug Abuse treatment services, to the public and may reveal identifying information such as my name and hometown. I understand that the information mentioned above is protected under the federal regulations governing Confidentiality of protected health information, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and/or 42 CFR Part 2, and cannot be disclosed without written consent unless otherwise provided for in the regulations. I understand that I am waiving any confidentiality rights or privileges that would otherwise prevent use of this information. I further understand that once the information is disclosed by this authorization the information could be re-disclosed. There is no guarantee the information will not be picked up by the media, make its way onto the internet, or be re-disclosed in some other way. Preferred Family Healthcare, its affiliates, employees and officers are not legally responsible or liable for the re-disclosure of the information authorized in this authorization.

I understand participation is voluntary and that I will not receive any compensation for the use of my name, image, story, quote or artwork.

This consent will expire four years from the date below unless there is a different specification of date, event, or condition noted:

Additional Conditions

I understand that I may revoke this consent at any time, but revocation is not retroactive and would not cover anything released while this consent was in place. Revocation must be in writing and may include specific items or the entire release.

I understand that I do not have to consent to the release of this information and that Preferred Family Healthcare will not deny or condition treatment or participation based on my consent.

I verify that a Preferred Family Healthcare representative has answered all of my questions regarding this release to my satisfaction.

Consent Date: 2021-09-18

I would like to receive a copy of this authorization