INDIVIDUAL AUTHORIZATION FOR RELEASE OF INFORMATION
We understand that information about you and your health is personal and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your written authorization before we may use or disclose your personal information (including protected health information) for the purposes described below. This form provides that authorization and helps us make sure that you are properly informed of how this information will be used or disclosed. Please read the information below carefully before agreeing to the terms of this authorization.
USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION
Who will use and disclose my information? GetWell Docent and Nuvance Health will disclose the information you submit about your Norwalk Hospital experience by electronically posting it to GetWell Docent and Nuvance Health websites, social media channels and other forms of media. GetWell Docent will send you messages regarding the status of your submission through email or text messages through a service provider of their choosing. GetWell Docent and Nuvance Health may use the information you submit to contact you to request permission to use the information you submit about your experience for other purposes. GetWell Docent may also use the information you submit about your experience for: (i) educational, training, and/or promotional purposes (ii) publicity, advertising (print, digital, and/or television), publications, and/or solicitation of contributions; (iii) commercialization, merchandising, and/or distribution; and/or (iv) broadcast and/or other public display or viewing.
Who will see my information? Anyone visiting GetWell Docent and Nuvance Health websites and social media channels may see or use the information you submit. Administrators of the email and text service provider GetWell Docent uses to send you status messages will also have access to limited information, primarily your email address and mobile phone number. In addition, in the event GetWell Docent or Nuvance Health uses your information as described above, members of the general public will see the information.
What information will be used or disclosed? The information used and disclosed will be limited to the information you submit through this website.
The information posted/disclosed on GetWell Docent and Nuvance Health websites and social media channels, or otherwise used and/or disclosed as described above, may include:
- your name
- the city/town, state/province/territory, and country where you live;
- the story of your care at Norwalk Hospital with information on your condition/injury, diagnosis, and treatment (including surgery if applicable);
- the name of your physician(s), therapist(s) and other caregivers; and
- your photo, audio and/or video (if provided).
If you submit sensitive information, that information will be deleted from your submission prior to your story being posted to websites and social media channels, or if the sensitive information cannot be deleted from your submission without compromising the integrity of your story, GetWell Docent and Nuvance Health may decline to post your submission altogether.
What is the purpose of the use or disclosure? The purpose of the use or disclosure is to share your Nuvance Health and Norwalk Hospital experience.
When will this authorization expire? This authorization will expire 15 years from the date you submit it to GetWell Docent. After the expiration of this authorization, GetWell Docent and Nuvance Health will not use or disclose your health information for the purposes described herein, unless you authorize such additional use or disclosure by submitting another authorization.
By agreeing to the terms of this authorization, you irrevocably authorize (only to the extent GetWell Docent and Nuvance Health have used such materials and information prior to revocation in accordance with these Terms & Conditions) the use or disclosure of your protected health information, as described above. This information may be re-disclosed if the recipient(s) described in this authorization is not required by law to protect the privacy of the information, and such information is no longer protected by federal health information privacy regulations. You hereby grant GetWell Docent and Nuvance Health a non-exclusive, perpetual, irrevocable (only to the extent GetWell Docent and Nuvance Health have used such materials and information prior to revocation in accordance with these Terms & Conditions), sublicenseable license to copy, excerpt, reformat, display, distribute and otherwise fully exploit and commercialize the materials and information provided to GetWell Docent and Nuvance Health in accordance with these Terms & Conditions.
You have a right to refuse to agree to the terms of this authorization. Your health care, the payment for your health care, and your health care benefits will not be affected if you do not agree to the terms of this authorization, but we will not be permitted to disclose your information as described on this authorization without your agreement.
You have a right to receive a copy of this authorization after you have agreed to its terms. If you would like a copy of this authorization, please send your request to: GetWell Docent at firstname.lastname@example.org
If you agree to the terms of this authorization, you will have the right to revoke it at any time, except to the extent that GetWell Docent or Nuvance Health has already taken action based upon your authorization. To revoke this authorization, please write to: GetWell Docent at email@example.com
Unless you represent below that you are the personal representative of an adult or minor patient, GetWell Docent and Nuvance Health will only post information about you. If you submit information about another patient or individual that could be considered protected health information, that information will be deleted from your submission prior to your story being posted to GetWell Docent and Nuvance Health websites and social media channels, or if the information cannot be deleted from your submission without compromising the integrity of your story, GetWell Docent and Nuvance Health may decline to post your submission altogether.
You hereby agree to waive any right to inspect or approve any finished product(s) incorporating the information or materials provided to GetWell Docent and Nuvance Health, including without limitation any picture, video, compilation, collective work, written copy, sound recordings and/or edited audio visual works that may be created and appear in connection therewith. You waive any claims you may have based on any usage of the information (including if applicable, your picture and likeness), without restriction as to changes or alternations, provided to GetWell Docent and Nuvance Health or materials derived therefrom, including, but not limited to, claims for additional compensation, invasion of privacy or libel.
You are of full age and competent to agree to these Terms & Conditions.
These Terms & Conditions shall be governed by and construed in accordance with the laws of the Commonwealth of Massachusetts, without regard to conflicts of law provisions thereof.