Healthcare Speaker Release Form

HEALTHCARE SPEAKER RELEASE FORM

Event/Program:    Date:    Location:

Speaker / Patient Information

Insurance & Medical Information (Optional)

Presentation & Materials

Release and Consent

For good and valuable consideration, the receipt and sufficiency of which I acknowledge, I, the undersigned Speaker/Patient, hereby grant to the Organization named below and its affiliates, licensees, successors and assigns an irrevocable, perpetual, transferable, worldwide right and license to record, reproduce, publish, distribute, display, edit, modify, translate and otherwise use my name, image, likeness, voice, biographical information, statements, testimonial, and presentation materials (collectively, the Materials) in any media now known or hereafter developed for educational, promotional, training, research, and outreach purposes.

I expressly authorize the Organization to use still images, audio recordings, video recordings, presentation slides, transcripts, and excerpts containing my Materials. I understand that such uses may include internal training, public presentations, printed materials, electronic media, social media, and archived materials.

I waive any right to inspect or approve the finished product or the use to which it may be applied, and I waive any right to royalty or other compensation arising from or related to the use of the Materials. I release and discharge the Organization, its officers, employees, contractors and agents from any claims, demands, liabilities or causes of action that I may have now or in the future arising out of or in connection with the use of the Materials, except to the extent caused by gross negligence or willful misconduct of the Organization.

Permissions (check all that apply)

Consent to audio and video recording of presentation and personal statements
Consent to use in printed and electronic publications, brochures and reports
Consent to use on organizational website(s) and archived online materials
Consent to use on social media, promotional, or advertising channels
Consent to use for educational, training, and research purposes

Authorization to Use Protected Health Information (PHI)

I authorize the Organization to use and disclose my protected health information as necessary to include health-related statements, diagnoses, treatment information, images or references to care provided in the Materials. Types of PHI to be disclosed may include dates of service, general diagnoses, and non-sensitive treatment descriptions. I understand that this authorization is voluntary and that refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits, except where the provision of the Materials is a condition of enrollment in a specific program.

I understand that once my PHI or Materials are disclosed pursuant to this authorization, the Organization may re-disclose such information and it may no longer be protected by federal privacy regulations.

Withdrawal and Limitations

I may revoke this authorization at any time by giving written notice to the Organization at the contact listed below. I understand that revocation will not apply to Materials already released or distributed in reliance on this authorization prior to receipt of my revocation. Revocation does not negate the Organization’s right to continue to use edited or archival materials already disseminated.

Representations, Indemnity & Governing Law

I represent that I am at least 18 years of age and have full authority to grant the rights granted herein. If I am signing as a parent or legal guardian for a minor, I represent that I am authorized to execute this Release on behalf of the minor. I agree to indemnify and hold harmless the Organization from any third-party claims arising out of my breach of representations made in this Release. This Release shall be governed by the laws of the state where the Organization is located, without regard to conflict of laws principles.

Organization Contact for Notices

Acknowledgment

By signing below, I acknowledge that I have read and understand this Release, that the terms are contractual and not a mere recital, and that I have had the opportunity to ask questions and consult counsel prior to signing. I affirm that I have the legal authority to grant the permissions described herein.

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