St. Charles Health System (“St. Charles”) seeks your permission to use your protected health information and your consent to allow us to take, use and disclose audio/video/photographic material (each, and collectively, the “Recordings”) of you, your minor child, protected person or ward in St. Charles internal and external communications, and distribute such Recordings online, in print, and in news media (such as TV, radio, newspapers, and magazines) for its business, commercial, promotional, or marketing use, including uses that may involve the exchange of financial remuneration. 

To ensure that St. Charles is acting in accordance with your wishes, and using protected health information with your authorization, we ask you to fill out and sign this form. St. Charles will keep a copy of your written permission on file. 


Protected health information may contain sensitive or specially-protected information. Please indicate those types of sensitive information that you authorize St. Charles to use and disclose as set forth above: 


I am aware that the protected health information published or disclosed pursuant to this Authorization may exist forever in either a recorded, printed, and/or electronic version or other version as may develop over time and that once it is published or disclosed in any form it may continue to be used. I understand that information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and will no longer be protected by the federal regulations protecting privacy of an individual’s health information under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable federal and state laws. 

By signing this Authorization form, I understand that: 

  • I have the right to revoke (take back or change your mind about) this Authorization at any time. To do this, a request must be made in writing and provided or mailed to the St. Charles Health System Manager of Health Information Management. 
  • I understand that I may restrict or withdraw this Authorization at any time to limit how St. Charles may use the information in the Recordings, except to the extent St. Charles has taken action in reliance on this Authorization prior to receipt of my revocation. 
  • No determination about treatment, payment, enrollment, or eligibility for benefits will be based on whether or not I sign this Authorization. 
  • I understand that federal confidentiality rules will not protect the medical information that I have authorized to be released, if it is released again by the organization or person that receives it. 
  • Unless I revoke this Authorization, it will expire twenty (20) years from the date of my signature below and that St. Charles may use the Recordings unless and until such expiration date or upon my written revocation of this Authorization. 
  • I will be provided a copy of this Authorization. 
The email address entered will receive a copy of this signed waiver.

By signing below, I hereby acknowledge and agree that I have read and understand the above Authorization and voluntarily agree to all terms described. 

Is the patient legally able to sign this waiver?

Please use your mouse to sign in the grey box below. If on a tablet or smartphone, sign using your finger/stylus.

Please use your mouse to sign in the grey box below. If on a tablet or smartphone, sign using your finger/stylus.