AUTHORIZATION FOR USE OF MY HEALTH INFORMATION FOR MARKETING/BROADCAST/PUBLICATION

My New Self Surgical Weight Loss Program is a service of Des Peres Hospital. Photo Authorization.

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulations
Des Peres Hospital is committed to protecting the privacy of your health information. As of April 14, 2003, a federal law known as the Health Insurance Portability and Accountability Act (HIPAA) gives you new protections regarding the use and release of your health information, in addition to those protections that already exist under Missouri law. This new federal law requires that we give you this authorization form for your review and signature.

Authorization to Use Health Information:
This authorization permits Des Peres Hospital to disclose the following information about your case and the treatment as follows:

Specific Information to be Disclosed: First name, city residence, type of surgery, pounds lost, photo or video/film, story you share
Recipients of the Information: website visitors, social media sites visitors, public, news media

This authorization also permits news media who are preparing news articles or broadcast stories to redisclose the above information about your case and the treatment to the general public in connection with a news broadcast or the publishing of a news article or story.

By submitting any photographs to Des Peres Hospital, through any medium, including social media, you agree that Des Peres Hospital has the perpetual right to modify the photographs and publish or republish the photographs or portions of the photographs, in any marketing and any medium. Des Peres Hospital, in its sole discretion, may credit you by name if it publishes your photographs.

You certify that (a) you are the patient in these photographs and that you had weight loss surgery at Des Peres Hospital as part of the MyNewSelf program, (b) you own the rights to the photographs you submit, (c) the photographs do not violate the rights of any third party, (d) the photographs have not been altered and do not convey a false or misleading impression, and (e) any additional information you submit is accurate.

If you wish to have your photo removed from the hospital’s sites, please e-mail despereshospital4@tenethealth.com. This request will not affect the hospital’s prior use of your photographs.

By clicking “Agree”, you agree that you will not be paid for any use of your photograph or other information by Des Peres Hospital, and agree that you will not hold Des Peres Hospital responsible for any injury in connection with the use, copying distribution or display of your image, voice, likeness, name or any other identifying characteristics in Des Peres Hospital’s materials.

Why does Des Peres Hospital engage in public relations efforts?
Des Peres Hospital is dedicated to high quality patient care. In order to educate the public about the work we do and about health issues generally, we may prepare, or assist newspaper, magazine, television or radio reporters in preparing, articles or broadcast or web stories regarding specific individual patients, their illness, and the treatment they have received.

Are the individuals who receive my health information pursuant to this authorization permitted to use or disclose it for other purposes?
Des Peres Hospital will not use or disclose your health information pursuant to this authorization for other purposes except with your written authorization or as specifically required or permitted by law. However, you understand that you are authorizing the disclosure of your health information for public and media publication. Once disclosed, federal privacy protections would not apply.

Questions? The address of Des Peres Hospital’s Privacy Office is 2345 Dougherty Ferry Road, St. Louis, MO 63122 and you may contact the Privacy Office by telephone at 314-966-9477.

By Clicking “Agree” I acknowledge that I have read and understand the terms of this authorization and I have had an opportunity to ask questions about Des Peres Hospital’s use or disclosure of my health information for marketing and possible use in broadcast or publication. I hereby knowingly and voluntarily authorize Des Peres Hospital to use or disclose my health information for the purposes stated herein.

Erica's Success Story after weight loss surgery at MyNewSelf Bariatrics in St. Louis, MO.
Erica

Erica said her doctor told her she was a metabolic time bomb waiting to go off. I was 40 years old. Two weeks after surgery, my knees feel wonderful, I run every day, I lift weights, I do all that stuff. The only medication I take now is vitamins.