Thank you for sharing your success photo/story with us. By submitting the online form you agree that this authorization permits Baylor Scott & White Medical Center at White Rock Lake to post the image you are uploading to the hospital website. Furthermore you understand that by posting your image, you are acknowledging and making public on this site that you had bariatric surgery at Baylor Scott & White Medical Center at White Rock Lake.

You also agree that you have read and understand the terms of this authorization and I have had an opportunity to ask questions about Baylor Scott & White Medical Center at White Rock Lake’s use or disclosure of my health information for possible use in broadcast or publication. I hereby knowingly and voluntarily authorize Baylor Scott & White Medical Center at White Rock Lake to use or disclose my health information for the purposes stated below.

 

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulations

Baylor Scott & White Medical Center at White Rock Lake 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 Texas law. This new federal law requires that we give you this authorization form for your review and signature.

Authorization to Use Health Information:

By giving Baylor Scott & White Medical Center at White Rock Lake permission to post your photo, you waive any right to compensation for such uses, and you and your successors or assigns also release and hold harmless Baylor Scott & White Medical Center at White Rock Lake, your attending health care provider and Facility from and against any claim for any injury in connection with the use, copying distribution or display of your image, voice, likeness, name or any other identifying characteristics in the broadcast or publication and any compensation resulting from the activities authorized by you in this authorization.

What if I later change my mind?

Providing consent to post your photo is entirely voluntary. If you change your mind at any time, you can revoke this authorization by providing a written notice of revocation to the following office: Baylor Scott & White Medical Center at White Rock Lake, Marketing Department at the following address: 9440 Poppy Drive, Dallas, TX 75218 stating that you are revoking your authorization. It will be effective upon receipt.

Are the individuals who receive my health information pursuant to this authorization permitted to use or disclose it for other purposes?

Baylor Scott & White Medical Center at White Rock Lake 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 media publication. Once disclosed, federal privacy protections would not apply.

Questions?

The address of Baylor Scott & White Medical Center at White Rock Lake Privacy Office is 9440 Poppy Drive, Dallas, TX 75218.