- I understand that I can choose whether I want my name and my child or children’s names used. If any quotes or related information about my family are to be used in print, I understand that I will be asked for my explicit consent.
- I understand that I am not required to sign this form in order to receive services from Child First or other services at the affiliate agency.
- I understand that the photographs and videos used or disclosed under this authorization may be reused by the recipient and may no longer be protected by the HIPAA privacy regulations.
- I understand that I may revoke or discontinue this authorization at any time by notifying the affiliate agency in
writing. It will be effective on the date the agency notifies Child First, Inc. (except to the extent action has already been taken based on my earlier authorization).
When completed, this form will be retained by the affiliate agency, and a copy will be provided to Child First, Inc.
