Media Release Form (Digital Version) - Valley Behavioral Health

Media Release Form

Valley Behavioral Health and its subsidiaries (The Carmen B. Pingree Autism Center of Learning, the Adult Autism Center of Lifetime Learning, and Highland Springs Specialty Clinics, hereafter referred to as VBH) creates and published media that helps promote the missions, goals, and successes of VBH programs and clients. All media created for this purpose is created with the subject’s dignity and privacy in mind.

We appreciate your willingness to take part in a media project. Please take a few moments to review this form, and let a VBH specialist or representative know if you have any questions or concerns!

Subject of media release
Program that subject is receiving services (if applicable)
PURPOSE: Valley may have the opportunity to recognize you or your minor child in the media or other public forums. This would be to share your experience with VBH and your progress towards recovery. This is voluntary. Services will not be withheld or compromised if you choose not to sign this form.
REVOKE: Information already disclosed based on this authorization cannot be revoked. If you want to revoke future disclosures, Valley will help you with this if it is possible. Once information is shared with the media, it becomes part of public records and is no longer protected under federal privacy and security rules.
By agreeing and signing this release form, you give Valley permission to use and/or disclose the following about you (or your minor child): (check all that apply)
Name of Event (Subject is only releasing image rights in relation to single event)
Images, recordings, and information released for single events cannot be revoked, but will only be used in relation to said event. Once information is shared with the media, it becomes part of public record and is no longer protected under federal privacy and security rules.
I give Valley the right to use and disclose information publicly or privately as identified above. I waive any rights, claims or interest I may have to control the use of my identity or likeness in the photographs, video or audio. I agree that any uses described in this form are made without compensation or additional interest to me. Any self disclosure of me or my child’s protected health information is not considered a use or disclosure by Valley. This agreement releases Valley, all employees, officers, and directors thereof from any liability that could arise from this use and/or disclosure. I represent that I have read and understand the above and I am competent to sign this agreement.
SUD Consent (if applicable)
I give my consent to be recognized as an SUD treatment client.

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