Newborn Announcement

Newborn Announcement

#BornAt7220
Baby's Name*

First NameMiddle NameLast Name
Birthday*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option
Pounds*
lbs.
Ounces*
oz.
Length*
inches
Delivered By*
Provider
Photo Upload

Optional
Cancelof

Newborn Announcement

Your Information
Parent(s)*
Full Name(s)
Email*
example@example.com
Hometown*

Street Address

Street Address Line 2

CityState

Zip Code
Acknowledgement*

I have read the complete Newborn Announcement Release below and authorize Ivinson Memorial Hospital to use or disclose protected health information for marketing and/or media purposes.

Newborn Announcement Release
This authorization allows Ivinson Memorial Hospital to use or disclose protected health information for marketing and/or media purposes.

Authorization
I authorize Ivinson Memorial Hospital to use or disclose to all appropriate media sources the following information:
- Name, age, birth stats, hometown.
- Background, family.
- Photo (if provided).
Purpose
The purpose and limitations (if any) of the requested use or disclosure:
- Media Stories.
- Marketing Communications.
Refusal
I may refuse to sign this authorization and understand that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits. Ivinson Memorial Hospital is not liable for breaches of confidentiality arising from unauthorized use of such information.

Revocation
I understand that I have the right to revoke this authorization at any time. If I want to revoke this authorization, I must do so in writing. I understand that such a revocation will not have any effect on any information already released. Ivinson Memorial Hospital is not responsible for any access or activity between the date of the original signature of this authorization and receipt of the revocation document.

[Section End]
Signature*

Clear
Signed*

MonthDayYear
Date
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