Patient Consent & Release of Protected Medical Information

Comments

This field is for validation purposes and should be left unchanged.

Patient Name(Required)

First Last

Date of Care(Required)

Permission is hereby granted to Emergency Care Alliance of Tennessee (CECATN) to utilize the information contained in the EMS run report for my care that occurred on the day listed above, in Tennessee. I understand that the EMS run report contains personal medical information that may, under state and federal laws, be considered confidential, and I hereby expressly waive my right to maintain the confidentiality of this medical information, so that the information in the EMS run report may be used by Children’s Emergency Care Alliance of Tennessee in connection with the EMS Star of Life Award Ceremony and all future marketing materials. This release and waiver include the potential publication of the information (to include any photos sent to CECATN) on television, radio and print media. I also expressly waive any and all claims that I might have against the EMS service that prepared the EMS run report and/or against Tennessee Emergency Medical Services for Children Foundation, in connection with the use of this information for the EMS Star of Life Award Ceremony.(Required)

Patient Signature (or guardian if under 18)

Date

Witness Signature(Required)

Date

Do you plan to attend the EMS Star of Life Awards Dinner & Ceremony with your Family? (Selection will not be based on attendance)(Required)

Yes