[If applicable: On behalf of the above named resident/individual] I hereby authorize Menorah Park, Inc.; Jewish Home of Central New York, Inc.; Jewish Home of Central New York Senior Apartments, Inc., Menorah Park Group Residences, Inc.; Syracuse Jewish Family Service, Inc., as applicable, and their staff and authorized representatives (collectively referred to as “Menorah Park”) to use and disclose information on the above named individual as described below.

By signing this form, I authorize the use and/or disclosure of my/the individual’s protected health information created or collected in conjunction with the following activities: interviews with myself/the individual or with Menorah Park staff; testimonials/reviews/activities; demonstrations; photography; audio/video recording; and any other legitimate media/marketing activity for Menorah Park in which the I/the individual voluntarily participates.

I understand that this may directly or indirectly identify me/the individual as receiving health services from Menorah Park and may reveal information about my/the individual’s health condition and treatment. By signing this form, I understand any health information obtained from the activities described above may be used or shared for any legitimate media, marketing, promotional and/or advertising purpose. That means my health information may be seen in newspapers and magazines, on websites and signage, on the television or radio. My/the individual’s information may also be published on the internet and social media websites.

Once my/the individual’s health information is published and/or posted, I understand other people or groups including Menorah Park may republish or repost it. I understand that media/marketing representatives do not have to follow federal privacy laws and my/the individual’s health information may no longer be protected once disclosed. This means that my/the individual’s health information may be re-disclosed without asking my permission. I also understand that Menorah Park may have no control over the editing or use of information once disclosed.

I understand that I do not have to sign this form. If I refuse to sign this form my/the individual’s medical treatment, payment, benefit eligibility, or enrollment activities will not be affected.

I understand I have the right to revoke this authorization at any time, except to the extent that action has already been taken based upon my authorization. To revoke this authorization, please write to:

Privacy Officer
Menorah Park
4101 East Genesee Street
Syracuse, New York 13214

If I revoke this authorization, the revocation will not affect any actions taken by Menorah Park before receiving my written revocation.

This authorization expires at the end of any marketing campaign, or when my/the individual’s information is no longer required for marketing or other purposes. I understand the media may continue to use and reuse my/the individual’s health information collected under this authorization indefinitely.