CONSENT TO USE OF IMAGE FOR NON-COMMERCIAL PURPOSES: ADULT
I give my permission to INDY Foundation to use my photograph and image publicly to promote INDY Foundation, its services, and its activities.
I understand the images may be used in print publications, online publication, social media, presentations, websites, and other communications by the INDY Foundation.
I understand that as part of its publications, social media, presentations, websites, and other communications by the INDY Foundation, the INDY Foundation may disclose certain health information about me. “Health Information” is defined as any information, whether oral or recorded in any form or medium, that: (A) is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and (B) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to any individual.” I consent to the INDY Foundation using and sharing my Health Information. Any exceptions to my consent must be given in explicit and written format to INDY Foundation along with this signed Consent to Use of Image for Non-Commercial Purposes form. I understand INDY Foundation is not a covered entity under the Health Insurance Portability and Accountability Act (HIPAA) and therefore is not required to provide any HIPAA notice(s) or waivers to me prior to its use of my Health Information.
I also understand that I will not receive any royalty payment, fee, or other compensation payable to me by reason of INDY Foundation’s use of the photograph or image.
I understand INDY Foundation may use my photograph and image for non-commercial purposes.
Please complete below and submit to accept these terms.
I understand the images may be used in print publications, online publication, social media, presentations, websites, and other communications by the INDY Foundation.
I understand that as part of its publications, social media, presentations, websites, and other communications by the INDY Foundation, the INDY Foundation may disclose certain health information about me. “Health Information” is defined as any information, whether oral or recorded in any form or medium, that: (A) is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and (B) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to any individual.” I consent to the INDY Foundation using and sharing my Health Information. Any exceptions to my consent must be given in explicit and written format to INDY Foundation along with this signed Consent to Use of Image for Non-Commercial Purposes form. I understand INDY Foundation is not a covered entity under the Health Insurance Portability and Accountability Act (HIPAA) and therefore is not required to provide any HIPAA notice(s) or waivers to me prior to its use of my Health Information.
I also understand that I will not receive any royalty payment, fee, or other compensation payable to me by reason of INDY Foundation’s use of the photograph or image.
I understand INDY Foundation may use my photograph and image for non-commercial purposes.
Please complete below and submit to accept these terms.
