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I understand and agree that any narratives, depictions, pictures, film, photographs, audio-visual or sound recordings or testimonials of me made by the Pediatric Retinal Research Foundation (PRRF) or its respective employees and agents may be used by PRRF, and those acting with permission, for illustration, broadcast, or testimonial shared with the general public in connection with the work of PRRF. I assign to PRRF all of my rights to these materials. I understand that these materials made by PRRF, its employees and agents are owned by PRRF and that they may copyright them. I further consent to allow PRRF, their respective employees and agents, and those acting with PRRF’s permission, to use my protected health information, as defined under 45 C.F.R. 164.501, for the purpose of illustration, broadcast, or testimonial in connection with any work of PRRF, and to release this information to the general public. I understand that these materials may be published on PRRF’s website, and this may disclose my personal and protected health information online. However, PRRF’s online disclosure of my name and residence will be limited to my child’s first name and the geographical location where he or she receives services. PRRF does not need to submit these materials to me for approval. I understand that these materials may be modified and that PRRF may decide not to use them. I acknowledge that the rights described above are granted to PRRF on an unlimited basis without any compensation or payment being made for any current or future use. I understand that my consent is voluntary, and that I may revoke my consent to allow PRRF to release my protected health information if that information has not already been disclosed. To revoke my consent, I must notify PRRF in writing. Such written notification must be sent to PRRF, Attn: Foundation Board President, PO Box 1926, Birmingham, MI 48012. I understand that a revocation is not effective to the extent that PRRF has relied on the use or disclosure of the protected health information. I understand and agree that once PRRF, its respective employees and agents, and those acting with permission, disclose my protected health information, this information may no longer be protected by the Health Insurance Portability and Accountability act of 1996. This release and authorization expire five (5) years from the date of my signature below. I have read this release and authorization before signing below, and I fully understand its contents.

PRRF Adult Publicity Release

Pediatric Retinal Research Foundation

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