Infant Physical Therapy Payment

I authorize Schreiber Center for Pediatric Development (Schreiber), its sponsors and community partners, to use my child’s likeness for media, promotional, or advertising purposes as outlined below, which may include my child’s protected health information about my child’s condition and treatment.

I consent to being interviewed, photographed, filmed, audio/video taped, and/or having my voice or image recorded by other electronic or non-electronic means by Schreiber, its employees, or such agents as it may engage for this purpose. I also authorize Schreiber to permit other individuals and entities, including but not limited to representatives of commercial or non-commercial newspaper, magazine, radio, or television related organizations to photograph/film, video/audio tape and otherwise record my child on Schreiber’s premises. I further understand that during any of the previously listed actions, my child’s health information may be disclosed, and unless otherwise noted, my child may be identified by name. I further consent to the publication and distribution of any of the things outlined above for Schreiber’s own publications or any other broadcast, print, or electronic media. I understand that any elements gathered by Schreiber or outside media may be edited or reused and I waive any right to inspect or approve my depictions in these works. I understand this authorization is voluntary and I will receive no compensation for the use or disclosure of my child’s protected health information for any of the uses described above. I understand that Schreiber or any of its affiliated providers cannot make me sign this authorization as a condition of my child’s treatment, and my refusal to authorize or disclose any of my child’s personal health information will in no way affect my eligibility to receive care at Schreiber. I understand this authorization will expire ten years from the date on which I signed it. I understand that I may cancel this authorization at any time by contacting the Fund Development at 717-393-0425 ext. 108, and that any revocation will not apply to any materials, in any format, that have already been created, published, or distributed, but will apply to publication or distribution of any future images based on this authorization. I understand that once my child’s health information is used or disclosed, it is no longer protected by state or federal law. I understand that once such materials are in possession of the media or members of the general public, Schreiber does not retain control over their editing or use.

I hereby release Schreiber and each of its trustees, officers, employees and agents, from any and all claims, liability and damages, which might arise from the use and/or disclosure of the health information, or which might arise from the use of my child’s name, interviews, photographs, films, video/audio tapes, or other recordings and images. I understand that I am entitled to a signed copy of this authorization.