Media consent and HIPAA authorization for release of photographs, recordings, or interviews.

I am completing this authorization for my minor child identified in this electronic form and named above and I hereby give my consent for my minor child to be photographed, recorded by audio or video and/or interviewed while a patient, visitor, associate, member or hired talent while on or off the premises of Health First and/or any of its affiliates, subsidiaries, locations, facilities and/or properties, including but not limited to, Cape Canaveral Hospital, Holmes Regional Medical Center, Palm Bay Hospital, Viera Hospital, Health First Medical Group or Health First Health Plans. I also authorize the use of the photograph(s), audio or video recording(s) and/or interview(s) intended to increase public knowledge and awareness of health services, health matters and health plans in any channel, including but not limited to, printed materials and online. I understand and agree that any photographs, recordings and interviews are the property of Health First and may be used by Health First for marketing, promotional, or general business purposes. 

I am completing this authorization for myself and I hereby give my consent to be photographed, recorded by audio or video and/or interviewed while a patient, visitor, associate, member or hired talent while on or off the premises of Health First and/or any of its affiliates, subsidiaries, locations, facilities and/or properties, including but not limited to, Cape Canaveral Hospital, Holmes Regional Medical Center, Palm Bay Hospital, Viera Hospital, Health First Medical Group or Health First Health Plans.

I also authorize the use of the photograph(s), audio or video recording(s) and/or interview(s) intended to increase public knowledge and awareness of health services, health matters and health plans in any channel, including but not limited to, printed materials and online. I understand and agree that any photographs, recordings and interviews are the property of Health First and may be used by Health First for marketing, promotional, or general business purposes. This consent and authorization to release PHI contains the entire understanding of the parties relating to the subject matter, and shall not be altered, modified, amended, waived or supplemented in any manner whatsoever except by a written agreement signed by both parties.