St. Luke's University Health Network

Patient Authorization for the Release of Protected Health Information in Media

  1. Authorization to Disclose. I authorize St. Luke’s University Health Network and its affiliates, and each of their employees, physicians and representatives (collectively, the "Network") to use and disclose health information about me in the form of interviews, photographs, and/or video/audio recordings. The purpose of such uses and disclosures would be for the promotion of the Network and its services, patient education, discussion of newsworthy topics, community reports, donor materials, or otherwise, whether appearing in newsletters, forums, advertising, publications, displays, written or audio media releases, digital media (including web pages, online advertising and forums, and social media), or other formats.

  2. Refusal to Sign. I understand that I may refuse to sign this Authorization. The Network may not refuse to treat me based on my refusal to sign this Authorization.

  3. Revocation of Authorization. I understand that I may revoke this Authorization at any time, in writing. My written revocation will become effective when the Network receives it. If I wish to revoke this Authorization, I will send a written request to: St. Luke’s University Health Network, 801 Ostrum Street, Bethlehem, PA 18015, Attention: Director, Marketing and Public Relations. Once this Authorization is revoked, the Network may no longer use or disclose my health information for the purposes listed in this Authorization. However, if the Network relied on my Authorization before it was revoked to create and disclose materials, the Network may continue to use and disclose those materials even after my authorization has been revoked.

  4. Further Disclosure. I understand that I am authorizing the disclosure of my health information (such as my name and my photograph, video/audio recordings, and/or interviews) which the Network will publish and distribute publicly. My health information may be further reproduced, copied or disclosed by those who receive or view the information, and once my information is no longer held by St. Luke’s, the federal laws governing patient privacy may no longer protect the information.

  5. Expiration of Authorization. I understand that this Authorization will expire twenty years from the date I sign it. Once this Authorization has expired, the Network may no longer use or disclose my health information for the purposes listed in this Authorization unless I sign a new Authorization.

St. Luke’s University Health Network Media Consent and Release

  1. Consent. I hereby consent to permit St. Luke’s University Health Network and its affiliates (the "Network") and the Network's designated media producer and editor (including any photographer and videographer) (the "Media") to take photographs of me and interview me, and to make video and/or audio recordings of me (the "Material").

  2. Permission to Use and Disclose. I hereby consent to permit the Network (and the Media, on the Network's behalf) to use and disclose the Material for any and all purposes relating to the promotion of the Network and its services, patient education, discussion of newsworthy topics, community reports, donor materials, or otherwise, whether appearing in any of the following "Displays": newsletters, forums, advertising, publications, displays, written or audio media releases, digital media (including web pages, online advertising and forums, and social media), or other formats.

  3. Withdrawal of Consent. I understand that I can ask that any photography, interview, or recording be stopped at any time, and that if I make such a request, my consent will be considered withdrawn. I may withdraw my consent after the Material has been produced, by sending a letter to St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015, Attention: Director, Marketing and Public Relations. Once my consent is withdrawn, the Network may no longer use or disclose my Material for the purposes listed in this consent. However, if the Network relied on my consent before it was revoked to create and disclose the Material, the Network may continue to use and disclose those Materials even after my consent has been revoked.

  4. No Approval Required. I understand that I have no right to inspect or approve the Displays in which my Material, or any part of my Material, may be used. However, I understand that the Network and the Media will use the Material in good taste.

  5. No Compensation. I understand that the Material will be the property of the Network or the Media. I waive any and all rights I may have in the Material. I understand and agree that I will not receive any compensation in any form from the Network or the Media, or from any other source as a result of my consent to have the Material taken, used, disclosed, or distributed.

  6. Release. I irrevocably release the Network, its employees and agents, and the Media from any and all liability arising from or connected with the taking, use, disclosure and distribution by the Network or the Media of the Material.

Patient Authorization for the Release of Protected Health Information in Media

Adult Acknowledgement:I understand the terms and meaning of this Authorization. I certify that I am 18 years of age or older.
Parent/Guardian Acknowledgement:I certify that I am the parent or legal guardian of the below named minor child and I understand the terms and meaning of this Authorization.

St. Luke’s University Health Network Media Consent and Release:

Adult Acknowledgement:I understand the terms and meaning of this Authorization. I certify that I am 18 years of age or older.
Parent/Guardian Acknowledgement:I certify that I am the parent or legal guardian of the below named minor child and I understand the terms and meaning of this Authorization.
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