I wish to help Grove Creek Medical Center and its affiliated entities in its marketing, public relations,
and fundraising efforts. As such, I hereby authorize Grove Creek Medical Center and its affiliated
entities to use and disclose information concerning the person named above to the public for
purposes of endorsing or marketing the services of Grove Creek Medical Center, its affiliates,
or its medical staff members, including the following:
This authorization will expire three years from the date it is executed unless I revoke it earlier. I
understand that I may revoke this authorization at any time unless Grove Creek Medical Center
has taken action in reliance on the authorization. To revoke authorization, I must submit a written
Grove Creek Medical CenterGCMC Attn: Director of Marketing & PR98 Poplar St.Blackfoot, ID 83221
I understand that Grove Creek Medical Center and its affiliated entities may not condition my
treatment on my provision of this authorization.
I understand that information disclosed pursuant to this authorization may be re-disclosed by
the recipient and no longer be protected by applicable law.
I have read and understand this authorization, and authorize the use of disclosure as
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