Share Your Success Story

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Your Story

I want to share my experience, but do not want my name included.

By choosing to submit a story on the Third Street Family Health Services Web site, you acknowledge and agree that any information you provide, may be viewed by the general public. You further agree that Third Street Family Health Services may use your story in any manner it deems necessary or appropriate. Third Street Family Health Services reserves the right to edit, abridge or format stories for any reason and to remove or decline to post any story. Third Street Family Health Services does not endorse or make any warranties or representations with regard to the accuracy, completeness or timeliness of any of the statements in your story. *

I authorize Third Street Family Health Services to take photographs, films, and/or video, interview me, publish articles(s) or provide information such as patient stories and testaments about me for the purpose of TSFHS publications, fundraising, publicity, promotion, web site or advertising for TSFHS or its affiliated entities.

Please choose all other options that you authorize Third Street Family Health Services to use.

Publications and newspapers, print media, radio, television, web site and all types of electronic communication media including social media.

Documenting my injury/condition for evaluation, insurance or legal reasons.

Briefly describe the nature of the project, including a specific description of what health/personal information will be involved, and the specific audience or type of audience that may be involved

I consent to the taking and use of the photographs, films, audio and/or video, or publishing of the attached article or information as described above, including placement in central repository for use by any TSFHS affiliated health care providers, i.e. reuse, unless otherwise indicated. I understand that I may be identified in any use of the above materials. I realize that I will not be compensated in any way for the taking or use of photographs, films, audio and/or videotapes, or the publishing of the attached article or information. I understand and agree that this Authorization is valid unless I cancel it in writing (as described in the next sentence) for as long as the Organization noted above (or any organization that succeeds it) stays in business. I understand that I may cancel this Authorization at any time (as long Organization noted above has not taken action in reliance on this Authorization) by mailing, faxing or taking a letter in person to the organizations indicated above. I understand that once my health information is used or disclosed, it is no longer protected by state or federal law. I understand that neither TSFHS nor any of its affiliated health care providers can make me sign the Authorization as a condition of getting treatment, making payments on any bills, or gaining enrollment or eligibility in any health insurance plan, unless the Federal Privacy Regulations allow it. I understand that if the Organization noted above will receive money or other compensation (either directly or indirectly) from someone else because of the use of my health information in my project described above. I have been told of the compensation. I agree that I have received a signed copy of the Authorization. *

I agree to the statement above.

Signature of patient, parent or guardian

Sign above

Date

If patient is not signing Authorization, state Relationship.

TSFHS Staff Name (print)

Phone Number

Media Outlet(s)/ Scheduled Date

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