By signing below, I authorize the release of certain health information of ____________________________(Print Name) (“Client”) as follows:
Who Can Release the Information: Res-Care, Inc. d/b/a BrightSpring Health Services and its subsidiaries (“Provider”).
What Information Can be Released:
• All of Client’s “Health Information,” which includes, but is not limited to, Client’s
o Identity
o Treatment received from Provider
o Diagnosis and health condition, including mental health diagnosis
o Prognosis
• Photos, videos and any images taken of Client (“Image Information”)
To Whom Can the Information be Released: The Health Information and Image Information can be used and released to the public through any means, including but not limited to, print media, TV, websites, blogs, and social media, including Facebook, LinkedIn, Instagram, Snapchat, Twitter, and YouTube. The Health Information and Image Information can also be released to employees and other personnel of Provider and all of its subsidiaries and affiliates (“Provider Personnel”).
Purpose of the Release: The Health Information and Image Information will be released for the following purposes:
• For Provider marketing and advertising its services to the public
• For Provider sharing information with Provider Personnel, including
o To educate Provider Personnel,
o To highlight employee performance
o To communicate success stories
o For internal marketing
Additional Acknowledgement and Agreement: I understand that once Health Information and Image Information are disclosed to the public they may be re-disclosed to others and will not be subject to protection under HIPAA or other privacy laws. I release, discharge and hold Provider harmless from any and all claims (including compensation) related to the Health Information and Image Information, including but not limited to, the use, reproduction, disclosure, publication, or display of the Health Information and Image Information. I relinquish and give to Provider all of Client’s rights, title, and interests in and to the Health Information and Image Information, including any rights of publicity or copyright which may exist now or in the future.
This Authorization binds the Client, the Client’s heirs, successors, assigns and representatives (including Guardians, parents and any other personal representatives). No promises have been made, or other inducements given to me to obtain this Authorization.
I understand that this Authorization expires within 180 days of the date noted below. I also understand that I have the right to revoke this Authorization by providing written notice to Provider at the email or postal address below. However, this Authorization may only be revoked with regard to future use of the Health Information and Image Information and will not be effective if Provider has already taken action based upon this Authorization prior to receiving my written notice of revocation. I also understand that I have a right to have a copy of this Authorization. I further understand that this Authorization is voluntary and that I may refuse to sign this Authorization. My refusal to sign this Authorization will not affect the Client’s ability to receive services from Provider, other benefits or enrollment for benefits, or payment for coverage of services.
Contact information to revoke Authorization:
BrightSpring Health Services
Attn: Corporate Communications
805 N. Whittington Parkway
Louisville, KY 40222
[email protected]
Accepted and Agreed:
Signature of Client/Patient: Date:
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I/we certify that I/we are the parent(s) or person(s) legally appointed the guardian(s) of the above named Client/Patient.
Signature of Parent/Guardian: Date:
Signature of Parent/Guardian: Date:
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BrightSpring Use Only
Agency/Office/Facility: Team Member/Agent:
EMAIL COMPLETED FORM immediately to
[email protected].
Subject of email should be Client’s full name. Retain original document in the employees personnel file.
Updated January 2020
