Bristol Hospice Media Release and HIPAA Authorization

Patient Information

If the individual signing this Authorization is not the patient:





For a deceased patient, “Personal Representative” means an executor, administrator, court appointed representative, or other individual authorized under applicable law to act on behalf of the deceased patient’s estate or privacy rights.

1. Authorization to Use and Disclose Information

I authorize Bristol Hospice, its affiliates, subsidiaries, employees, agents, contractors, representatives, successors, assigns, and the Bristol Hospice Foundation (collectively, “Bristol”) to use, disclose, publish, reproduce, distribute, display, transmit, and otherwise use the following information concerning me or the patient identified above:

  • Photographs, video recordings, audio recordings, and other media;
  • Name, image, likeness, voice, and appearance;
  • Written, recorded, or spoken testimonials, statements, interviews, and personal stories;
  • Information regarding the patient’s hospice experience and care journey;
  • Information regarding services provided by Bristol;
  • Information regarding charitable support, financial assistance, grants, goods, services, or benefits received from the Bristol Hospice Foundation;
  • Health information voluntarily shared in connection with a testimonial, interview, patient story, Foundation assistance story, photograph, video, or other Media, including information relating to diagnosis, treatment, prognosis, medical condition, hospice care, or care experience; and
  • Any additional information specifically described below:

2. Purpose of Use and Disclosure

I understand and agree that Bristol may use and disclose the information authorized above for lawful business purposes, including:

  • Marketing and advertising;
  • Public relations and media communications;
  • Community outreach;
  • Educational and informational materials;
  • Fundraising activities;
  • Foundation related communications and campaigns;
  • Websites, social media platforms, digital communications, and online content;
  • Print publications, newsletters, brochures, annual reports, presentations, and promotional materials; and
  • Other communications relating to Bristol Hospice and the Bristol Hospice Foundation.

3. Participant Content Preferences

Please indicate the information and materials Bristol may use by checking all boxes that apply:







I understand that Bristol may use only the categories selected above.

4. Consent and Grant of Rights

I grant Bristol a worldwide right and permission to record, photograph, film, interview, reproduce, edit, publish, distribute, display, transmit, and otherwise use the information and Media authorized under this Authorization in any format or medium now known or later developed.

I understand that Bristol may use the authorized information and Media in marketing, advertising, fundraising, public relations, educational materials, community outreach, Foundation related communications, social media, websites, digital content, print publications, presentations, and other lawful business activities.

I understand that Bristol may combine the authorized information and Media with other photographs, videos, audio recordings, graphics, artwork, text, testimonials, stories, and other materials.

The rights granted under this Authorization shall remain effective unless and until this Authorization is revoked in accordance with Section 11. Any revocation shall apply only prospectively and shall not affect Bristol’s continued use of materials created, published, distributed, displayed, posted, broadcast, or otherwise released before Bristol receives the revocation.

I acknowledge that information and Media disclosed pursuant to this Authorization may continue to appear in previously published materials, archived content, third party publications, social media platforms, websites, search engine results, and other locations beyond Bristol’s control following revocation.

5. Ownership of Media

I understand and agree that all photographs, recordings, videos, interviews, testimonials, stories, and other Media created by or for Bristol shall be the sole and exclusive property of Bristol.

I waive any right to inspect or approve any final publication, advertisement, video, social media post, fundraising appeal, or other material before its use or distribution.

6. Testimonials and Storytelling

I authorize Bristol to use my or the patient’s statements, quotations, testimonials, interviews, and personal stories.

I understand that Bristol may edit testimonials, stories, interviews, and related materials for length, clarity, formatting, style, production, and publication purposes, provided the substance of the testimonial or story is not materially altered.

For deceased patients, this Authorization also permits Bristol to use information provided by family members, caregivers, and authorized personal representatives regarding the patient’s life, care experience, interactions with Bristol Hospice, and assistance received through the Bristol Hospice Foundation.

7. Foundation Assistance Authorization

I specifically authorize Bristol Hospice and the Bristol Hospice Foundation to identify me or the patient as a recipient of charitable assistance and to describe the nature of such assistance in connection with fundraising, charitable, educational, promotional, community outreach, public relations, or Foundation related materials.

8. No Compensation

I understand that neither I nor the patient will receive compensation, royalties, payments, or other consideration now or in the future arising from Bristol’s use of the authorized information or Media.

9. Voluntary Authorization

I understand that signing this Authorization is voluntary.

I further understand that my decision whether to sign this Authorization will not affect:

  • Eligibility for hospice services;
  • The quality or availability of care;
  • Payment for healthcare services;
  • Enrollment in any plan, program, or benefit; or
  • Eligibility for charitable assistance or benefits from the Bristol Hospice Foundation.

10. Potential Re-Disclosure

I understand that information disclosed pursuant to this Authorization may be publicly disclosed and may be re-disclosed by recipients.

Once information is publicly disclosed, it may no longer be protected by federal privacy laws, including HIPAA, and Bristol cannot control or prevent further disclosure by third parties.

11. Right to Revoke

I understand that I may revoke this Authorization at any time by providing written notice to Bristol Hospice.

Revocation will not affect any use, disclosure, publication, distribution, or other action already taken in reliance upon this Authorization before Bristol receives the revocation.

I understand that Bristol cannot recall, retrieve, remove, or prevent further dissemination of materials that have already been published, distributed, broadcast, posted online, or otherwise released before receiving my revocation.

12. Expiration

This Authorization shall remain effective unless and until revoked in writing by the patient or the patient’s authorized personal representative.

I understand that any revocation will apply only to future uses and disclosures and will not affect:

  • Any use or disclosure made in reliance on this Authorization before Bristol receives the revocation;
  • Any materials already created, published, distributed, displayed, posted online, incorporated into marketing, fundraising, educational, public relations, or promotional materials, or otherwise released before the revocation; or
  • Bristol’s inability to retrieve, remove, control, or prevent further dissemination of information or materials that have already been publicly disclosed or shared with third parties.

I understand that information and Media disclosed pursuant to this Authorization before revocation may continue to exist in previously published materials, archived content, third party websites, social media platforms, search engine results, and other locations beyond Bristol’s control.

13. Personal Representative Certifications

If I am signing on behalf of the patient, including a deceased patient, I represent and warrant that:

  • I have legal authority to act on behalf of the patient or the patient’s estate;
  • I have authority to authorize the use and disclosure of the patient’s protected health information, likeness, photographs, videos, testimonials, and personal story as described in this Authorization;
  • The information provided regarding my authority is accurate and complete; and
  • Bristol may rely on my representations without further investigation.

14. Release and Hold Harmless

To the fullest extent permitted by law, I release and hold harmless Bristol Hospice, the Bristol Hospice Foundation, and their respective affiliates, officers, directors, employees, contractors, agents, representatives, successors, and assigns from any claims arising out of or relating to the authorized use of the Media and information described in this Authorization, including claims for invasion of privacy, violation of publicity rights, misappropriation of likeness, or defamation.

Acknowledgment and Authorization

By signing below, I acknowledge that I have read and understand this Authorization, have had an opportunity to ask questions, and voluntarily authorize Bristol Hospice and the Bristol Hospice Foundation to use and disclose the information described above. I understand the rights I am granting, including the right to revoke this Authorization in accordance with Section 11, and I acknowledge that information disclosed pursuant to this Authorization may become publicly available and may no longer be protected by HIPAA once disclosed.