I, hereby authorize Anchorage Community Mental Health Services, Inc. and its wholly-owned subsidiaries (“the Organization”) to release images (likeness), art work, poetry, essay, transcribed recordings, descriptions, quotes, etc. in the publications, advocacy, or marketing pieces produced by the agency.
In giving my consent, I hereby release and hold harmless the Organization, their offices, employees, and designees from any and all responsibility or liability. I need not sign this form in order to ensure treatment, payment, enrollment, or eligibility for benefits.
I understand that I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to Clinical Records. I understand that the revocation will not apply to information that has already been released in reliance upon it. Furthermore, I understand that any Protected Health Information, once released into the public under this authorization, is no longer protected by the Organization’s privacy practices. This authorization will expire 1 year after the date of my signature, unless otherwise revoked.
I understand that I may obtain a copy of the information to be used or disclosed as provided in 45 CFR 164.