Media Release Media Release -Non Patient PHOTOGRAPHY AND MEDIA CONSENT I authorize CareOregon, and those acting for CareOregon, to record my name, likeness, voice, participation, comments and/or appearance in audio/visual media, including, but not limited to, video, sound and photographic still images or written material. These recordings, images, statements, health information and written material may be disclosed to the general public for the purpose of publicizing and promoting CareOregon and its affiliated organizations (CareOregon Advantage, Health Share of Oregon, Housecall Providers, Columbia Pacific CCO, Way to Wellville, Jackson Care Connect and Yamhill Community Care Organization) in any medium, present or future, including, but not limited to, print, Internet, social media networks, public presentations, speeches, video or audio. I understand that CareOregon and its affiliated organizations are not responsible for the unauthorized use of my name, likeness, voice, printed or biographical material by third parties, including, but not limited to, news media, Internet, or social media networks such as YouTube, Facebook, Linked In or Flickr, or other distribution networks that may be developed, now or in the future. I release CareOregon and its affiliated organizations from any and all liability for such uses or disclosures. I understand that if the person or organization receiving these images or information is not a health care provider or a health plan covered by federal privacy laws, the information listed above could be given out by them, and it will no longer be protected by privacy regulations. I understand that I may refuse to sign this form, and that I do not need to sign it. I understand that I may change my mind and decide to revoke this permission at any time. However, I understand that this permission is in effect until I revoke it. I understand that if I do choose to revoke permission, I need to do that in writing, and send the letter to CareOregon Communications Department, 315 SW Fifth Ave., Portland, OR 97204. I also understand that if I cancel this authorization, the information may already have been used or given out before I changed my mind and cannot be rescinded. I understand that I can ask for a member of the CareOregon staff to help me understand how this form will be used.By checking this box and typing my name below:* I represent that I am at least 18 years of age and that I have read and fully understood the above paragraphs, and am executing this release knowingly and voluntarily. 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