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Media Release Form

Contact Information

Name *

Telephone Number *

Address

Consent For Marketing

As evidenced by checking the box below, I give Horizon Behavioral Health consent and permission for the production, use, and release of my name, picture(s)/ photograph(s)/likeness(s)/image(s) (hereinafter referred to as “photograph(s)”), whether in print, electronic or video format for the purposes of public relations/ marketing publication in: Newspapers, Agency brochures, Other printed materials, Show/broadcast by means of a video, television, or internet transmission. *

As evidenced by checking the box below, this consent and release shall constitute written consent pursuant to Virginia Code Sections 18.2-216.1 et seq and 8.01-40 and -40.1 et seq, as amended, to use my photograph, including video photographs (or the photograph, including video photographs of the person, for whom I am signing), for marketing, advertising, trade or other commercial purposes. *

I understand that the photographing, videotaping, or digital recording is being conducted with my consent. I also understand if I am (or the individual for whom I am signing this consent form is) a client of Horizon, the use of these materials, which contain my photograph (no matter the format), may reveal that I am, or have been, a client of Horizon. I agree to waive my right (or the right of the person for whom I am signing) to keep private and confidential the fact that I am (or the person for whom I am signing is) a client, employee or associate of Horizon. I agree not to hold Horizon liable for use of my photograph, or the resulting use, publication, or broadcasting of these materials for public relations/marketing purposes. I agree that I have had the opportunity to discuss any concerns regarding this consent and understand the benefits and risks, if any, in signing this form. *

I understand that I may revoke my consent for the use of my photograph at any time, in writing, except to the extent that Horizon has already acted upon my consent, released the materials into the public domain, or included my photograph in advertising or marketing materials, and that my refusal to consent to the release of this information will prevent the disclosure of such information, but will not affect the health care services I presently receive, or will receive, from Horizon. I understand that a photograph or image of my likeness is considered to be a form of protected health information as defined by the federal Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA), and by Virginia’s Health Records Privacy Act (Section 32.1-127.1:03 of the Code of Virginia, 1950, as amended). I acknowledge that I will be asked to sign an additional Authorization for Disclosure of Protected Health Information form to further document my agreement to release of information, including the fact that I am (or the individual for whom I am signing this consent form is) a client or patient of Horizon. *

I understand that I may revoke my consent for the use of these materials at any time, except to the extent that Horizon has already acted upon it or released the materials into a public domain. *

Signature

Please type your name below as evidence of your signature. *

NOTE: If the individual is a minor or unable to consent, the parent or guardian must also sign this Consent Form as evidenced by typing their name below.

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