The Arc of the Capital Area (the Arc) is always pleased when a client is willing to communicate the stories, experiences, and information about his or her services at the Arc. The Arc respects the privacy of our clients, visitors and staff. Ensuring that health information is kept confidential is among our highest priorities.
The Arc seeks your consent to allow us to take and use audio/video/photographic material of you in our internal and external communications, including social media such as Facebook, twitter, Insta-gram, and google+, general interest and to distribute such materials online, in print and in news media (such as TV, radio, newspapers and magazines).
We will keep a copy of your written permission on file. If not revoked/withdrawn by me, this authorization expires ten (10) years from the date that I sign it. I understand that I may revoke this Authorization at any time by providing The Arc with written notice stating that the Authorization is cancelled. However, I understand that the revocation will not affect uses or disclosures that oc-curred prior to the date that The Arc received the revocation. If I decide to sign this form, I have the right to request that audio/video recording, filming, or photographing cease at any time. I am aware that my personal information will 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 will continue to be used.
Once my personal information is disclosed to the persons or organizations authorized by this form, my personal information has the potential to be further disclosed by these parties and would no longer be protected by the HIPAA Privacy Rule. The Arc is not responsible for any such subsequent disclosures.
I acknowledge that I have read and understand this form, and have been provided a copy of this form for my records. I understand that I may access and copy the information described on this form. I acknowledge that I do not have to sign this authorization form in order to receive any services from The Arc or in order to receive any other health care treatment, payment, enrollment in a health plan, or eligibility for benefits.