Media/Public Relations Authorization for the Use and Disclosure of Protected Health Information

On occasion ATI Physical Therapy will have an opportunity to promote our organization and our programs.  Such promotions will be in the form of media and marketing.  Since we cannot photograph, video or audio tape, or write articles about our clients without obtaining their permission, we must receive a written Media/Public Relations Authorization.  This is voluntary and the organization will not and cannot require you to sign it.  By agreeing and signing the Media/Public Relations Authorization form below, you will give ATI Physical Therapy permission to photograph, video or audio tape, or write articles about you. 

I authorize ATI Physical Therapy to disclose to media representatives and/or public affairs staff members my protected health information including my condition and/or reason for treatment for purposes of publicity, promotion, education or publication in print, broadcast and electronic and social media. This authorization includes my likeness on photo, videotape and digital media.

1. I authorize ATI Physical Therapy to disclose to media representatives and/or public affairs staff members protected health information and information about me, my condition or treatment for purposes of publicity, promotion, education or publication in print, broadcast and electronic and social media. This authorization includes my likeness on photo, videotape and digital media.  
2. This authorization expires 10 years from the date that I sign this authorization.
3. I understand that once my protected health information is used and/or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient(s).
4. I understand that I have the right to revoke this authorization at any time. My revocation must be in writing as described in the Notice of Privacy Practices. I understand that such revocation shall be effective for future uses and disclosures, but such revocation shall not be effective for information already used or disclosed.  I understand that once my health information is used or disclosed, it is no longer protected by state or federal law.
5. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from ATI Physical Therapy nor will it affect my eligibility for benefits.
6. I understand that I have a right to inspect and copy my own protected health information to be used or disclosed in accordance with the Notice of Privacy Practices.
7. I understand that I will not be compensated in any way for the taking or use of photographs, films, audio and/or videotapes, or the publishing of any article or information.
8. I understand that I may revoke this Authorization at any time by notifying the Digital Marketing Manager, Cori Cameron at 630-269-2222 ext. 7160 via a phone call or in writing to marketing@atipt.com, but if I do, it will not have any effect on any actions ATI took before it received the revocation.
9. I understand that there is potential for information disclosed based on this authorization to be subject to re- disclosure by the recipient and no longer be protected by the Privacy Rule.