I hereby voluntarily give Bayhealth Medical Center, Inc. (Bayhealth) a non-exclusive right to use the content of this story entry sent to Bayhealth, for use in any Bayhealth marketing or advertising materials at Bayhealth’s discretion. I understand that Bayhealth, and in some cases the organizations with which it has partnered, has/shall have all legal rights to the story entry content and any attachments as provided herein, and that I give up any and all rights to these organizations and will not receive any payment or compensation for the same now or in the future. I understand that Bayhealth shall be under no obligation to use the story entry content or any attachments. I understand that the story entry content, any attachments, or my name could appear on Bayhealth’s website and/or elsewhere on the Internet.
I hereby release and discharge Bayhealth, its subsidiaries, and their employees, agents, and representatives from any claims, liability, or results caused by the use of the story entry content and/or any attachments as provided herein.
By submitting my story and any attachments, I authorize Bayhealth, at its discretion, to interview my Bayhealth doctor(s), nurse(s), and/or other caregivers to confirm, supplement, and/or clarify the information provided in my story entry and attachment(s). I understand that such staff interview(s) may result in a limited disclosure of my protected health information (PHI), in the form of facts necessary to ensure the accuracy of any account based on my story entry content and/or any attachments, but that no medical records will be released. Bayhealth will not reveal any PHI as part of Your Story without prior authorization per privacy regulations of the state and Health Insurance Portability and Accountability Act (HIPAA). I understand that Bayhealth may use my name, location, photograph, and information provided in your submission of Your Story.
By submitting my story and any attachments, I also authorize Bayhealth, at its discretion to contact me in the future to confirm, supplement, and/or clarify the information provided in my story entry and attachment(s), or for further use of my story for marketing or advertising purposes.
I understand that whether or not I choose to sign this authorization (tell us your story) will in no way influence the health care services provided to me by Bayhealth.
I understand that I may revoke this authorization at any time by providing written notice to Bayhealth addressed to: Bayhealth Risk Management , 640 South State Street, Dover, DE 19901. However, such revocation shall not affect Bayhealth’s right to use the story entry content or any attachments submitted prior to my revocation of this authorization. I understand that Bayhealth will make its best efforts to remove my story entry and protected health information from Bayhealth’s website and the internet.
By checking the box above, I am indicating that I have read and agree to the terms and conditions.
