Resident Authorization for Public Disclosure | Documents and Links

Form 8 of 12

Note: Fields marked with an * indicates required field

Please indicate 'Yes' or 'No' for each of the following:

I authorize Marwood Nursing and Rehab, a subsidiary of McLaren Port Huron, to photograph and-or videotape me. These images may be used for promotions and marketing of the facility and its healthcare partners, and may be included in advertisements, newsletters, brochures, and other printed publications, as well as on television programs, our website, etc. : *

YesNo

I authorize the media (i.e., newspaper, radio, TV stations or other news media) to photograph, audiotape and-or videotape me and that imagery and broadcasts may be used by the media organization involved: *

YesNo

I authorize the release of information about me to the media and/or McLaren Port Huron publications, and I understand that it may include protected health information about me regarding my health status or medical treatment received. I also understand that information released pursuant to this authorization may be subject to redisclosure and no longer protected by the laws applying to medical information disclosures: *

YesNo

I certify that I have received a copy of this authorization and understand that I will not receive financial remuneration for participating in this media project.

This authorization will expire on Dec. 31, 2022. I understand I may cancel this authorization prior to its expiration to prevent the future release of information. Cancellation requests must be submitted in writing to Community Relations, Marwood Nursing & Rehab, 1300 Beard St., Port Huron, MI 48060.

DATE: *

RESIDENT NAME: *

ADDRESS: *

CITY: *

STATE: *

ZIP CODE: *

TELEPHONE: *

EMAIL:

RESIDENT - RESPONSIBLE PARTY: *

SIGNATURE: *

OFFICE USE: Send original to Admissions, provide resident with copy and retain one for the department file.