Ver en Español
View medical records, test results, book appointments, manage family's care, pay bills and more.
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:
By signing below, I hereby acknowledge and agree that I have read and understand the above Authorization and voluntarily agree to all terms described.
Please use your mouse to sign in the grey box below. If on a tablet or smartphone, sign using your finger/stylus.