MEDIA CONSENT TO PHOTOGRAPH, INTERVIEW AND PUBLISH INFORMATION, STATEMENTS OR IMAGES
I give my consent to Physician Group of Arizona to photograph or permit other persons to photograph, record, conduct media interviews and/or publish information, statements or images obtained while under the care or on the premises of Physician Group of Arizona.
I agree that the photographs and/or radio or television broadcast recordings and/or images may be used in any internal and/or external publications or broadcast formats, including radio, television, internet, print or any other means. I agree that Physician Group of Arizona may use and permit other persons to use the negatives or prints prepared from such photographs for such purposes and in such a manner as its representatives deem appropriate. I understand and agree that the photographs, recording and/or publication may reveal my identity. I agree that the photographs may be used for any purpose, including, but not limited to, dissemination to Physician Group of Arizona, physicians, health care professionals and members of the public for education, treatment, research, scientific, marketing, public relations, promotional and charitable purposes, and that such dissemination may be accomplished in any manner.
I consent to the taking and use of photographs, recordings and interviews of me, and to the publication of such photographs, recordings, and interviews, and to the publication of information, statements or images of or about me. By signing this authorization and consent form, I hereby waive any right to compensation for such uses, and I and my successors or assigns hereby hold Physician Group of Arizona, its administrators, directors, officers, employees or agents and related entities harmless from and against any claim for any injury, and any compensation, resulting from the activities authorized by me in this consent form.
The term “photograph” as used in the foregoing agreement, shall mean motion picture, digital imaging or still photography in any format, as well as videotape, video disc and any other mechanical means of recording and reproducing images.
I hereby waive my right under relevant state laws to patient confidentiality with respect to the taking or publishing of any photograph, recording, interview, statement or image of me, as authorized in this consent form, with the exception of those limitations specifically identified by me in this consent form. I understand that I have the right to revoke this waiver by notifying the Physician Group of Arizona in writing.
I hereby certify that I am at least eighteen (18) years of age and competent to contract in my own name insofar as the above is concerned.