Resident Authorization for Public Disclosure

Form 8 of 9

I authorize Marwood Nursing & Rehab, a subsidiary of McLaren Port Huron, to photograph and/or videotape me. These images may be used for promotions and marketing of the facility and its healthcare partners, and may be included in advertisements, newsletters, brochures, and other printed publications, as well as on television programs, our website, etc.

I authorize the media (i.e., The Times Herald, radio / TV stations or other news media) to photograph, audiotape and/or videotape me and that imagery and broadcasts may be used by the media organization involved.

I authorize the release of information about me to the media and/or McLaren Port Huron publications, and I understand that it may include protected health information about me regarding my health status or medical treatment received. I also understand that information released pursuant to this authorization may be subject to redisclosure and no longer protected by the laws applying to medical information disclosures.

I understand that I am not required to sign this form and that refusal to take part will not change the provision of healthcare services available to me at Marwood Nursing & Rehab.

I certify that I have received a copy of this authorization and understand that I will not receive financial remuneration for participating in this media project.

I understand I may cancel this authorization prior to its expiration to prevent the future release of information. Cancellation requests must be submitted in writing to:

Account Payable, Marwood Nursing & Rehab, 1300 Beard St., Port Huron, MI 48060.