Consent to use patient stories and photos

Versión en Español


  • I authorize my child (or myself) to be interviewed and/or photographed or filmed, or to have medical information about him/her released publicly, for the purposes of publicity and marketing (e.g. media stories, social media sharing, marketing/PR/Foundation communications to benefit Children’s Nebraska, etc.) by the Marketing department of Children’s (including Children’s Nebraska, Children’s Specialty Physicians, Children’s Physicians & Children’s Foundation), and the content may be shared with Children’s employees and the public.

    I understand that I may revoke this authorization at any time, except to the extent that action has already been taking in reliance upon it, by giving written notice to Children’s Vice President of Marketing & Community Relations. I also understand that I may request a copy of this authorization. I understand that refusal to sign this authorization will not affect care received at Children’s, costs or care or eligibility of benefits. My authorization is provided freely, and I understand that I will not receive compensation for the use/disclosure of the information. I understand this authorization is in effect unless Children’s ceases operations. I understand that information used/disclosed pursuant to this authorization may be subject to re-disclosure by third parties and is no longer protected under the HIPAA Privacy Rules.


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