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The DAISY Award for Extraordinary Nurses is an international program that rewards and celebrates the extraordinary clinical skill and compassionate care given by nurses. Lawrence Memorial Hospital has been a DAISY Award partner since 2012, recognizing an LMH nurse with this special honor every quarter. Learn more

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Authorization for Media Release – Photography, Video, Interview or Testimonial

I authorize LMH Health to disclose my name, medical photos and the medical condition(s) to media representatives selected by LMH Health, its employees, agents, representatives and other personnel (collectively known as “Media Representatives”) who are acting on behalf of LMH Health, or through interviews, photographs, audiotapes, and/or films (including digital media (“Materials”) for public disseminations by LMH Health or media. These Materials may be copied and distributed by means of various communication methods (i.e., photographs, video, TV, hospital-owned websites, social media platforms, You Tube, news bulletins, billboards or signs, brochures and postcards).

The purpose of this disclosure is to allow authorized LMH Health staff to record Materials and for LMH Health to disseminate health information to the general public. I also authorize Media Representatives to interview the patient’s treating physician(s) and/or staff who provided direct treatment to the patient, and to discuss details of the patient’s medical condition(s). I understand that if I do not sign this release form that my refusal to sign will not affect my ability to receive treatment.

I agree that any Materials taken shall be the sole and exclusive property of LMH Health or Media Representatives, and that they may use the Materials for educational and marketing purposes. I hereby waive any right to inspect or approve the finished product, or any material in which LMH Health may eventually use the images and protected health information, now or in the future, and without any notice to me. This permission form and release shall be binding upon my (or the patient’s) heirs, successors, assigns and legal representatives. I authorize the above without expecting payment, and I release LMH Health and its Media Representatives for any and all liabilities which may arise from the use of Materials.

I understand that this authorization may be revoked at any time except to the extent action has been taken in reliance upon it. Furthermore, I understand that this authorization will remain in effect unless specifically revoked by me. Revocation must be made in writing to LMH Health, Director of Communications, Marketing and Community Outreach, 316 Maine St., Lawrence, KS 66044.

Furthermore, I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal law.

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