Authorization for use/disclosure of information and consent for use audio/video/ photograph images under the HIPAA – Health Information Portability and Accountability Act of 1996
Ally Medical is proud when patients share their experiences about the care and treatment they received at our emergency rooms. Your story can help others who are interested in knowing more about the emergency care services provided by Ally Medical.
We respect the privacy of our patients, visitors, and staff and ensure that medical information is kept confidential. By your story submission, Ally Medical accepts your permission to use your shared medical information via audio/video/photographic material provided by you in our internal and external communications, including medical and general interest publications and medical and patient education information, and to distribute such materials online and in news media, such as TV, radio, newspapers, and magazines.
To ensure that Ally Medical is acting in accordance with your wishes, using your personal information with your submission confirms that you:
Do give permission for Ally Medical to use your name and share details of your treatment and experience as a patient in communications produced by or on behalf of Ally Medical, and consent to take and make use of your audio/ video/ photographic images in media communications produced by or on behalf of Ally Medical. This permission extends both to electronic versions on Ally Medical websites and other internet/electronic applications as well as to printed, filmed, and recorded versions.
Do give the right to request that audio/video recording, filming, or photographing cease at any time. You are aware that your protected health information will exist forever in either a recorded, printed, and/or electronic version or other versions that may develop over time and that once it is published or disclosed in any form, it will continue to be used.
Do understand that information about you disclosed per this authorization may be subject to re-disclosure by the recipient and will no longer be protected by the federal regulations protecting the privacy of an individual’s health information under the Health Information Portability and Accountability Act of 1996 (“HIPAA”) and other applicable federal and state law.
Do understand that you may revoke or withdraw this permission at any time to prohibit future use of my information. To do so, you must send written notice to Ally Medical Administrative Offices, 5525 Burnet Road, Suite A, Austin, Texas 78756.
Do understand that Ally Medical, as well as other persons or entities, will retain copies of any such electronic or printed versions and shall retain these versions forever and that any revocation of this authorization will only extend to the versions of the information within Ally Medical’s control.
