Additional Information Regarding Use of Patient Information

When you submit a story to UW Health, we ask your permission to use the information for our media purposes. On the form you submit, we ask for your signature. However, you should be aware of the following guidelines in signing the authorization:
No Obligation to Sign. You are under no obligation to sign this form, and you may refuse to do so. Unless permitted by applicable law, UW Health Care Providers may not refuse to provide you treatment or other health care services if you refuse to sign this form.
Revocation. You have the right to revoke this authorization, in writing, at any time before it ends. Your written revocation will be effective except to the extent that the person(s) and/or organization(s) listed on this form have taken action in reliance on this authorization. Your revocation must be made in writing and addressed to UW Health Marketing and Public Affairs, 635 Science Drive, Madison, WI 53711
Re-release. You should be aware that if the person(s) and/or organization(s) authorized by this form to use your image/demographic information are not health care providers or people subject to federal health privacy laws, information they receive may lose its protection under federal health privacy laws, and those people may be permitted to re-release your medical information without your prior permission.

Right to inspect. You have the right to inspect or copy information whose use or disclosure you are authorizing, with certain exceptions provided under state and federal law. If you would like to inspect the information to be disclosed, contact the UW Health/Marketing and Public Affairs office at (608) 262-6343.

*UW Health includes University of Wisconsin Medical Foundation, Inc.,
University of Wisconsin Hospital and Clinics Authority and UW School of Medicine and Public Health.