Do you have a story to share about your experience at Cookeville Regional? We'd love to hear about it. Please share below. Share Now *denotes required fields First Name * Last Name * Address Address 2 City Country State Zip Email * Telephone 1 * Telephone 2 Your Story * Please review the consent form and check the box below before submitting your story. PATIENT CONSENT TO PHOTOGRAPH / VIDEOTAPE / FILM / INTERVIEW AND/OR AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION I understand that, in the instance of external sources (such as media outlets or law enforcement agents), Cookeville Regional Medical Center, Cookeville Regional Charitable Foundation, Cumberland River Hospital and Cookeville Regional Medical Group are acting only as the intermediary, making it possible for the aforementioned source(s) to contact me. As such, I relieve and hereby agree to hold Cookeville Regional Medical Center, Cookeville Regional Charitable Foundation, Cumberland River Hospital and Cookeville Regional Medical Group free and harmless from any and all liability arising out of the use and/or release of information; interview; photograph/videotape/film; and subsequent publication or broadcast. I understand that the interview(s) or photo session(s) are being carried out upon my consent and authorization and so assume full responsibility. I understand that: I may refuse to sign this authorization and that it is strictly voluntary. If I do not sign this form, my health care and the payment for my health care will not be affected. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. If the requester or receiver is not a health plan or health care provider, the released information may be redisclosed by the recipient and may no longer be protected by federal privacy regulations. I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it. I get a copy of this form after I sign it. Patient consents to be: Photographed Filmed Videotaped Purpose of Use/Disclosure: Publication in newspaper(s), magazine(s) or other publications Social and digital media/website Broadcast by radio or television To document the progress of my care Cookeville Regional Medical Center, Cookeville Regional Charitable Foundation and Cookeville Regional Medical Group marketing and public relations materials/publications Description of Protected Health Information to be Used or Disclosed: All Patient Identifying Information; Age/Date of Birth City of Residence Nature of Injuries/Illness Patient Name * Birth Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1898189919001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018 Signature * Todays Date * Month MonthDec Day Day15 Year Year2018 Representative Relationship Agree 5 Year * I agree to allow CRMC to use my story for 5 years* Agree Terms * I have read the above and authorized the disclosure of the protected health information as stated*