Consent to publish photographs and/or recordings

1. I, the undersigned, a participant in the production and recording of video (or other recording) at Hospital for Special Surgery (or the parent, legal guardian, or person authorized to consent to such participation), hereby give my consent to the taking of any and all still photographs, films, television and/or video tapes, voice recordings, and/or other recordings ("Recordings") of me/your person at the Hospital for Special Surgery (the "Hospital") during the course of my/your participation in (the "Event") agrees to the use of the Recordings as follows: For any educational, training, solicitation, marketing, promotional or other purpose, in any medium, by the Hospital and/or by any person or persons the Hospital may name:

and/or for any broadcast or other public viewing. Such recording may be used as described above, in full or edited form, and may be incorporated into other recordings or formats and may be copied for multiple distribution and/or broadcast purposes.
 

2. I agree that I will not receive any compensation or other remuneration for the taking, production, use, transmission and/or distribution of said Recordings or for my participation in any way in said Event, and I specifically release the Hospital and all others from any liability or other obligation arising from the taking, production, use, transmission, and/or distribution of said Recordings and from my participation in the Event.
 

3.  I understand that I have the right to withdraw from participating in the Recording at any time during the Event and that I have the right to revoke this consent at any time to the extent that the Hospital and/or its designee have not relied on it, or have not sent Recording for use on external media.

Note: If the entrant is under the age of 18, the permission of the entrant's parent, legal guardian or authorized person is required. If the participant decides to revoke their authorization, write to the Public Relations Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, as soon as that decision is made.

Terms and Conditions

INDIVIDUAL AUTHORIZATION FOR RELEASE OF INFORMATION

We understand that information about you and your health is personal and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your written authorization before we can use or disclose your protected health information for the purposes described below. This form provides that authorization and helps us make sure that you are properly informed about how this information will be used or disclosed. Please read the following information carefully before agreeing to the terms of this authorization.

USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION

Who will use and disclose my information? HSS will disclose the information you submit about your experience with HSS by posting it electronically at www.hss.edu and/or on HSS social media channels. HSS will send you messages about the status of your shipment through the email service provider chosen by HSS (currently MailChimp). HSS may use the information you submit to contact you and request permission to use the information you submit about your experience with HSS for other purposes. HSS may also use the information you submit about your experience with HSS for: (i) educational, training, and/or promotional purposes at HSS and/or elsewhere; (ii) publicity, publicity (print, digital and/or television), publications and/or solicitation of contributions; and/or (iii) broadcast and/or other public display or display.

Who will see my information? Information you submit can be seen or used by anyone visiting www.hss.edu and/or HSS social media channels. The administrators of the email service provider that HSS uses to send you status messages will also have access to limited information, primarily your email address. Additionally, in the event HSS uses your information as described above, members of the general public will see the information.

What information will be used or disclosed? The information used and disclosed will be limited to the information you submit through this website.
Information posted/disclosed on www.hss.edu and/or HSS social media channels, or used and/or disclosed as described above, may include:

• Your name is
• The city/town, state/province/territory, and country where you live;
• The history of your HSS care with information about your condition/injury, diagnosis, and treatment (including surgery, if applicable); 
• The name of your doctor(s) HSS therapist(s), therapist(s), and other caregivers; and your photo and/or video.

The information disclosed to HSS's email service provider, and used by HSS to contact you, will include your:

• Name; 
• and Email. 

If you submit sensitive information, that information will be removed from your submission before your story is published on www.hss.edu and/or HSS social media channels, or if the sensitive information cannot be removed from your submission without compromising the integrity of your story, HSS may refuse to publish your submission in its entirety. The following types of information are considered confidential and will not be published or disclosed:

• HIV-related information (which is any information that indicates that you have had an HIV-related test, or have HIV infection, HIV-related illness or AIDS, or any information that may indicate that you have been potentially exposed to HIV )
• Substance abuse information;
• Psychiatric/psychotherapeutic care information;
• Sexually transmitted disease information;
• Tuberculosis information; and 
• Genetic information.

What is the purpose of the use or disclosure? The purpose of the use or disclosure is to share your experience with HSS.

When will this authorization expire? This authorization will expire 15 years from the date it is sent by an HSS. After the expiration of this authorization, HSS will not use or disclose your health information for the purposes described in this document, unless you authorize such further use or disclosure by submitting another authorization.

SPECIFIC UNDERSTANDINGS

By agreeing to the terms of this authorization, you consent to the use or disclosure of your protected health information, as described above. This information may be redisclosed if the recipient(s) described in this authorization is not required by law to protect the privacy of the information, and such information is no longer protected by federal health information privacy regulations.

You have the right to refuse to accept the terms of this authorization. Your health care, payment for your health care, and your health care benefits will not be affected if you do not agree to the terms of this authorization, but we will not be permitted to disclose your information as described in this authorization without your consent.

You have the right to receive a copy of this authorization after you have agreed to its terms. If you would like a copy of this authorization, please send your request to: Hospital for Special Surgery, Web Department, 535 East 70th Street, New York, NY 10021.

If you agree to the terms of this authorization, you have the right to revoke it at any time, except to the extent that HSS has already taken action based on your authorization. To revoke this authorization, write to Hospital for Special Surgery, Web Department, 535 East 70th Street, New York, NY 10021.

Unless you state below that you are the personal representative of an adult or minor patient, HSS will only release information about you. If you submit information about another patient or individual that could be considered protected health information, that information will be removed from your submission before your story is published on www.hss.edu and/or HSS social media channels, or if the information cannot be removed from your submission without compromising the integrity of your story, HSS may refuse to publish your submission in its entirety.