I hereby voluntarily authorize CHI Saint Joseph Health (CHI Entity) or its parent corporation, subsidiaries, affiliates, agents, contractors, providers or employees to include the following information about me and my practice in the CHI Entity’s website or printed physician directory:
- Name and photograph
- Practice name, address, phone and fax
- Specialty, subspecialty and medical society memberships
- Board Certifications
- Undergraduate and medical education with graduation dates
- Language(s) spoken other than English
- Accepting new patients
- Insurance plans accepted
- Affiliations – Hospitals, CINs, etc
I understand that I may refuse to sign this Authorization, that there is no obligation to participate in the Physician Directory, and refusing to participate will not affect my medical staff membership or the services I provide at CHI Entity.
I agree to hold the CHI Entity harmless, and its parent corporation, subsidiaries, affiliates, agents, officers, contractors, providers, directors, and employees, or other third parties designated by these entities or individuals that are involved in the production, duplication, publication, or any other use or disclosure of the photograph, practice and professional information for any damages, losses or disclosures incurred by such use or disclosure of the photographs or interview material. I also understand that the photographs or practice and professional information used or disclosed pursuant to this Authorization may be re-disclosed by a recipient and such cannot be controlled by any of the aforementioned parties.
In addition, I waive all rights to or conditions on the use or disclosure of my photograph and practice information that I may have and waive any claim for payment or royalties related to the use or disclosure of the photographs or interview material (whether such is for charitable or commercial purpose) by the CHI Entity, its parent corporation, subsidiary, affiliate, or any other party involved in any use or disclosure now or in the future.
I further understand and agree that these photographs or interview material may be used beyond the initial purpose and expiration date, if any listed below, for archival or historical purposes by CHI Entity, its parent corporation, subsidiaries or affiliates.
Expiration: This Authorization expires on March 31, 2025. (Authorization to be renewed annually)
Revocation
I understand that I may revoke this Authorization at any time by notifying CHI Saint Joseph Health in writing by sending a letter to:
CHI Saint Joseph Health
ATTN: Mar/Comm Department
1451 Harrodsburg Road, Suite D-502
Lexington, KY 40504
or completing the Provider Directory Update Request form.
I understand that if I revoke this Authorization, it will not affect any actions that CHI Saint Joseph Health took before it received my revocation letter. For example, CHI Saint Joseph Health cannot rescind disclosures it has already made.
This Authorization is binding:*