Authorization Release Form

I hereby authorize Hospice & Palliative Care of Buffalo, 225 Como Park Blvd., Cheektowaga NY 14227 (Hospice) to use and disclose my individually identifiable information as described below.  I understand that Hospice may contract with a third party to develop audiovisual materials. 

Specific description of information that may be used and disclosed:  PHOTOS, SLIDES, DISPLAY BOARDS, AND/OR VIDEO, INCLUDING INTERNET, TELEVISION, RADIO AND PRINT PUBLICATIONS.

The specific purpose(s) of the use or disclosure is(are) (indicate if the individual requested the use or disclosure and the purpose was not disclosed): to educate, advocate and publicly share Hospice & Palliative care buffalo services and/or research to board of trustees members, staff and volunteers of Hospice & Palliative Care Buffalo, Healthcare professionals, a Third Party marketing firm, the media and the lay public on the many services and/or research available through Hospice and its affiliate agencies.

Important Information Regarding this Authorization:

1. I understand that the organization providing the information cannot guarantee that the recipient of the information will not re-disclose the information if the recipient described on this form is not required by law to protect the privacy of the information.

2. I understand that Hospice may use or disclose my information for the purpose identified above, and that my authorization expires when my information is no longer needed for this purpose.

3. I understand that this authorization is voluntary and that my refusal to sign this authorization will not affect me as a patient (health care, payment for health care and/or health care benefits) or as an employee (employment and/or employee benefits).

4. I understand I may obtain a copy of this form after I sign it.

5. I understand that I may withdraw my Authorization at any time; if I withdraw my Authorization, Hospice may not use my information going forward except to the extent that it has already relied on my Authorization.

6. I understand that Hospice will not receive direct or indirect remuneration for communications about products or services that contain my information.