AUDIO / VIDEO AND PHOTOGRAPHIC RELEASE FORM

    AUDIO / VIDEO AND PHOTOGRAPHIC RELEASE FORM

    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:

    • Comments by the person or the person's representative concerning the care or treatment they received at Grove Creek Medical Center.
    • Photographs, video, or audio of the individual, family, or significant others.

    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
    request to:

    Grove Creek Medical Center
    GCMC Attn: Director of Marketing & PR
    98 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
    described above.


    Use your finger or mouse to draw your signature in the box below.