Please fill out, review, and submit the following patient information. The patient, a patient representative, or a Shepherd Center employee must submit the form. 

I authorize Shepherd Center, Inc. (the "Hospital") and its employees, marketing and publicity agencies, independent contractors, agents, and consultants (collectively, "Shepherd"), and the mass media to photograph, film, videotape, and/or interview, and/or identify me. I also authorize the above-referenced parties to disclose such images and confidential information, including protected health information ("PHI"), such as my status as a current or former patient of the Hospital and descriptions of the treatment that I recieve(d), for marketing and internal training purposes. 

I further understand that:

• Shepherd does not expect to receive any direct or indirect compensation for these uses. 
• I do not have to sign this Authorization and Release Agreement ("Authorization") to access treatment, medical care, or other services from the Hospital and staff.
• Hospital will not disclose my medical records pursuant to this Authorization, although I acknowledge that the Hospital will still have the right to disclose my medical records as otherwise permitted by HIPPA.
• I may revoke this Authorization in writing at any time, except to the extent we have already relied on it in obtaining or disclosing such information, by sending the revocation by First Class Mail to: Shepherd Center, Inc., Attn: Privacy Officer, 2020 Peachtree Road, NW, Atlanta, Georgia 30309. The revocation will be effective when the Shepherd Center Privacy Officer receives it.
• Shepherd, and members of the mass media, may use photographs, videos and other depictions or descriptions of me, my medical condition and my treatment information in broadcast, print or electronic (e.g., television, radio, newspaper, magazine); Hospital publications (e.g., magazines, newsletters, advertisements, brochures); and internet websites. 
• Shepherd does not and cannot control the use or misuse of the images and other information after publication on the website or in other published media. 
• Recipients of these communications may redisclose this information to others. If redisclosed, the information will no longer be protected by HIPAA and other Federal and State privacy laws. 
• Shepherd and the mass media may use photographs, videos or other depictions of my family and friends in the same manner.
• Specific photographs or other materials that individually identify me cannot be used in published media without my consent, which I hereby give freely, and this written Authorization.
• The Hospital cannot condition my access to treatment, admission, or medical services upon signing this Authorization.
• I am entitled to receive or retain a copy of this Authorization 
• This Authorization and consent to public disclosure of confidential information, including PHI, and waiver of confidentiality in this Authorization is being made solely for the benefit of Shepherd and without any expectation that I or my family will receive any compensation, remuneration, or other benefit. 

By checking "yes" and clicking submit I agree to consent.