I do hereby authorize Cancer Services (CS) and its duly authorized employees or agents, to obtain and publish my photograph, video, and/or personal health information/story (e.g., information relating to diagnosis, treatment, and health care services provided or to be provided to me and which identifies my name and other personally identifiable information) to be used in print media, on the radio, TV, the CS website, blog and/or on the following social media platforms: Facebook, Twitter, Instagram, LinkedIn and/or YouTube.
I understand that my photograph, video and/or personal information may be used for instruction, teaching and future research for myself, attendants, family members and professionals in the field of healthcare. My photograph, video and/or personal information may also be used for advertising and public relations purposes, published institutional and/or area newsletters, community awareness, and may appear on local television stations.
I understand that my photograph, video, and/or personal health information/story may be released via the social media platform(s) above and may be subject to re-disclosure by such social media platform(s) and may no longer be protected by applicable Federal and State privacy laws.
I understand that my image and any statements made by myself may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness and/or statement appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image, statements or recording. I hereby release, acquit and discharge Cancer Services, their current and former agents, affiliates, officers and employees from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs, statements and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.
I understand that I have a right to revoke this authorization by providing written notice to Cancer Services, 550 Lobdell Avenue, Baton Rouge, LA 70806. However, this authorization may not be revoked if CS, its employees or agents have taken action on this authorization prior to receiving my written notice. This authorization will remain in effect for ten (10) years from the signature date or from the date I revoke my permission.
I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to seek resources with CS, eligibility for benefits or enrollment or payment for or coverage of services.
