Confidentiality and Liability Agreement
I hereby agree to exercise good faith and to protect donor information and monetary transactions/acquisitions on behalf of Prisma Health Midlands Foundation. I agree not to use any information/knowledge gained for my personal benefit or for the benefit of others. I also give full permission for the use of my name and photograph taken in connection with Prisma Health Midlands Foundation and related events.
I hereby remiss, release and forever discharge Prisma Health Midlands Foundation from, and agree to indemnify Prisma Health Midlands Foundation against any liability, cost or expense resulting from any and all actions, causes of action, claims and demands which we might otherwise have in respect of any injury, damage or loss that we might suffer.
I have provided Prisma Health Midlands Foundation with information, pictures and perhaps other forms of media (collectively “Information”) that relates to my personal health. The confidentiality and privacy of some or all of the Information is protected by State and/or Federal laws.
I agree that Prisma Health Midlands Foundation, in the course of its mission to promote improved healthcare for the citizens of South Carolina in general, Richland County in particular, may disclose the Information to members of the public, both directly and/or indirectly through news and/or entertainment media. When solicited for purposes of publication in newspapers, magazines or other printed media, or broadcast by means of radio or television transmission, I recognize that Prisma Health Midlands Foundation may also act as an intermediary, and make it possible for the broadcaster or publisher to contact me directly. I agree that any process by which the Information is released is carried out with my consent.
I release and hereby agree to hold Prisma Health Midlands Foundation free and harmless from any and all liability arising from my being interviewed or photographed or the subsequent publication or broadcasting of any or all of the information.
Prisma Health Midlands Foundation and the Prisma Health hospitals have not conditioned treatment, payment, enrollment or eligibility for benefits upon my signing this authorization. I reserve the right to cancel or revoke this authorization at any time.
Any such cancellation or revocation must be made in writing and will be effective only to the extent Prisma Health Midlands Foundation has not already acted in reliance on this authorization.
This authorization will be effective for three years unless otherwise stated.
