100th Anniversary – DCH Baby Stories

100th Anniversary – DCH Baby Stories

Are you a DCH baby?
Patient's Full Name*

First NameMiddle NameLast NameMaiden Name
Email*
example@example.com
Phone Number
Please enter a valid phone number so we may reach you if needed.
Physician Who Delivered You
Tell us your birth story:
I authorize the release of protected health information to be disclosed in the following manner:
I agree to allow photos provided by me to be published publicly by a representative of the DCH Health System Marketing/Communications Department, and I understand that my photo and personal information may appear in DCH promotional material (advertisement, publication, video, website, social media, etc.).
I understand that I will be identified by name.
The purpose for the use/disclosure of this information is hospital publicity or public education.

I understand that I have the right to 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 the revocation to the DCH Health Information Management Department (Medical Records). I understand that revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization for use will expire six (6) years from the date of submission.

I understand that authorizing the disclosure of health information is voluntary. I can refuse to sign this authorization. I need not sign this authorization in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided by 45CFR 164.52-54. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by the federal confidentiality rules.
Electronic Signature*

Clear
If submitting on behalf of the person named above, please state your relationship to patient:
Today's Date*

MonthDayYear
Please upload your photo(s):

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