ONLINE CONSENT AGREEMENT with HIPAA Privacy Authorization Form
This agreement (“Agreement”) is between Lightbox Entertainment Inc. (including its assigns, licensees and affiliated persons and entities) (collectively, the “Producer”), and the undersigned contributor (the “Contributor”). In exchange for good and valuable consideration (receipt of which is acknowledged by the Contributor), including the opportunity for the Contributor to appear in a documentary-style television currently titled “Diagnosis” (the “Program”), the Contributor agrees as follows:
1. The Contributor grants the Producer the right and permission to film, photograph, record, use, and recreate the Contributor’s name, image, voice, likeness, biographical material and accounts of the Contributor’s life, including all written, tape recorded and other material supplied by the Contributor to the Producer (collectively, the “Materials”), in connection with the Program (including advertising, promotion and ancillary products associated with the Program), without restriction, in all media, throughout the world, in perpetuity. The Contributor acknowledges that the Producer shall be the exclusive owner of all rights in the Program and that the Producer shall have the right to assign or license those rights without restriction.
2. The Contributor understands that the Producer and its assignees and/or licensees are relying upon this Agreement in spending time, money and effort on the Program and the Contributor’s participation in it, and that this Agreement, for this and other reasons, cannot be revoked.
3. The Contributor agrees not to bring any claim (whether now known or hereafter discovered) related to the Program or its production, against the Producer or anyone associated with the Program, including but not limited to claims involving assertions of (i) invasion of privacy, (ii) infringement of rights of publicity or misappropriation (such as any allegedly improper or unauthorized use of anyone’s name or likeness or image), (iii) failure to use the Materials in the Program, in whole or in part, (iv) false light (such as any allegedly false or misleading portrayal of the Contributor) or defamation, (v) damages or injuries of any kind, including alleged damages resulting from physical injury, embarrassment, loss of reputation or emotional distress, (vi) fraud (such as any alleged deception about the Program or this consent agreement), (vii) copyright or trademark infringement, or (viii) any alleged moral rights. The Participant also agrees not to make any claim for temporary, preliminary, or permanent injunctive relief.
4. Contributor represents and warrants that all communications (oral, written, or otherwise) made by the Contributor to the Producer in connection with the Program will be factually accurate and based entirely on Contributor’s own personal perception/experience. The Contributor acknowledges that other parties will be interviewed in connection with the Program and agrees not to bring any claim, as provided for in paragraph 3 or otherwise, in connection with any statement, inference or allegation made about the Contributor by any such third party or by the Producer in reliance on statements made by such third parties.
5. The Contributor acknowledges that the Producer may interview doctors and other health care professionals in connection with the Program, and that the Contributor agrees to sign a HIPAA release form authorizing such health care professionals to release medical information (possibly including mental health information and other sensitive personal data) about the Contributor, attached hereto as Exhibit A. The Contributor further acknowledges that the Producer is not a health care professional, nor does the Producer have any health care expertise, and the Producer is not responsible for, nor makes any representations or warranties of any kind with respect to, any treatment, opinion or other medical diagnosis or advice sought by or given to the Contributor at any time before, during or after production of the Program, all of which would be sought by and/or undertaken by the Contributor independently and irrespective of the Contributor’s participation in the Program.
6. The Contributor agrees that without the prior approval of the Producer and the broadcasting network (the “Network”), the Contributor shall not discuss this Agreement, the Program or the Contributor’s participation in the Program with any third party, except that the Contributor may make incidental, non-derogatory mention that the Contributor participated in the Program only after the earlier of the exhibition of the episode(s) in which the Contributor appears or the public announcement by the Network of the Contributor’s participation in the Program. The Contributor agrees not to make any commercial use of the Contributor’s appearance in the Program. Nor shall the Contributor or anyone acting on the Contributor’s behalf at any time use any of the Producer’s or the Network’s names, logos, trade names or trademarks (including, but not limited to, the title of the Program), or those of any of the Producer’s or the Network’s related companies, for any purpose.
7. This is the entire agreement between the Contributor and the Producer in relation to the Program, and the Contributor is not relying on any statements or promises not specifically included in the terms of this Agreement.
8. Although the Contributor agrees not to bring any claim in connection with the Program or its production, if any claim nevertheless is made, the Contributor agrees that any such claim must be brought before, and adjudicated by, only a competent court located in the State and County of Los Angeles, and governed by the substantive laws of the California.
9. The Contributor represents and warrants that the Contributor has authority to enter into this Agreement and to grant the rights set forth herein without the consent of any third party.
AGREED AND ACCEPTED:
Lightbox Entertainment Inc. (“Producer”)
________________________________ By: ____________________________
EXHIBIT A: HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
REQUEST AND AUTHORIZATION FOR DISCLOSURE AND REDISCLOSUREOF MEDICAL/PSYCHOLOGICAL/PSYCHIATRIC INFORMATION (“AUTHORIZATION”)
This Authorization is being requested by me in accordance with applicable law, including the Confidentiality of Medical Information Act, Section 56, et seq., of the California Civil Code and the Health Insurance Portability and Accountability Act of 1996, specifically 45 CFR section 164.508(c).
I hereby request and authorize any licensed physician, medical practitioner, hospital, clinic, health maintenance organization or other medical or medically-related facility, insurance company, or other organization, institution or person (collectively referred to as “Practitioner and Facility”), that has any records, information or knowledge of me or my medical/psychological/psychiatric condition or health, to disclose to Lightbox Entertainment Inc.. (“Producer”), [NETWORK]. and any television network, cable outlet, or other television outlet on which the Program (as defined below) may be broadcast (“Network”), and each of their respective licensees, successors and assigns, and each of their respective officers, directors, agents, representatives and employees (collectively referred to as “Licensees and Agents”), any and all medical/psychological/psychiatric records, test results, documents, medical advice, laboratory work, X-rays, video and photographs of me (including video and photographs of me undergoing surgical and/or other medical procedures and therapies), notes and assessments, diagnosis, hospitalization or treatment of me, and other information, relating to my medical condition, medical history, mental, emotional or physical condition (collectively referred to as “Records”). I am aware that these Records may contain information concerning any or all of the following: psychiatric or psychological testing or treatment; emotional problems; prescription drug use; alcohol or drug abuse; and/or my general physical health (including but not limited to my history regarding physical abuse, sexually transmitted diseases, and the like).
I understand that the Practitioner and Facility is required by law to keep my health information confidential. I understand and agree that by authorization of the disclosure of my Records to someone who is not legally required to keep it confidential, these Records will no longer be protected by state or federal confidentiality laws and will be disclosed and/or redisclosed to Producer, the Network, and Licensees and Agents, as Producer in its sole discretion deems necessary, and may be further disclosed by Producer to other third parties, for purposes of producing, promoting and otherwise exploiting the television program currently untitled (the “Program”) (and all allied, subsidiary and ancillary rights therein), in any and all media, now known and hereafter devised, throughout the universe, in perpetuity, and for any other purposes designated by Producer. Without limiting the foregoing, I further understand and agree that Producer intends to feature me in the Program, including filming me undergoing surgical and/or other medical procedures and therapies and interviewing my family/friends and Practitioner and Facility about my medical history and condition(s) and, as such, I agree that my health information and Records may be included in the Program (and all allied, subsidiary and ancillary rights therein and promotions therefor), for distribution and exploitation in any and all media, now known and hereafter devised, throughout the universe, in perpetuity.
I understand that by agreeing to this Authorization, I am waiving rights I would ordinarily have to keep my Records confidential and prevent Producer and Network from utilizing my Records in, and in connection with, the Program. I knowingly and freely waive these rights and consent to the Practitioner and Facility’s, Producer’s and Network’s dissemination of the Records to third parties for use in and in connection with the Program. This Authorization to release Records is voluntary. I am not required to sign this Authorization in order to receive treatment or medical review or testing by Practitioner and Facility, or for enrollment in a health plan or eligibility for benefits. However, should I fail to sign this Authorization, I understand and agree that I will be ineligible to participate in the Program.
To the maximum extent permitted by law, I hereby release Practitioner and Facility, Producer, Network, and Licensees and Agents, on my own behalf and on behalf of my successors and assigns, from any claim of any kind or nature whatsoever arising from the accessing, obtaining, disclosing, broadcasting, or using in any way, the Records, and/or my participation in the Program (including without limitation, those claims based upon defamation, invasion of privacy, right of publicity, breach of confidential relationship, personal injury, intentional or negligent infliction of emotional distress, loss of earnings or potential earnings, copyright, trademark or any other personal and/or property rights) (“Claims”) and agree that I will not now or in the future assert or maintain any Claims against Practitioner and Facility, Producer, Network and Licensees and Agents. In connection with the foregoing releases, I hereby expressly waive any and all rights and benefits conferred by the provisions of Section 1542 of the California Civil Code or by any similar law or provision of any jurisdiction throughout the world. Section 1542 reads as follows: “A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS FAVOR AT THE TIME OF EXECUTING THE RELEASE WHICH, IF KNOWN BY HIM, MUST HAVE MATERIALLY AFFECTED HIS SETTLEMENT WITH THE DEBTOR.”
This Authorization will remain valid for the term of my involvement in any way in connection with the Program, including, without limitation, in connection with the production of the Program. I may revoke this Authorization at any time, provided that the revocation is not effective to the extent that Producer and Network has already relied on the use or disclosure of the Records or on the right to access such Records. Such revocation must be in writing, signed by me and received by Lightbox Entertainment, Inc., Attention: Erika Schroeder , [ADDRESS], before the Practitioner’s dissemination of the Records to Producer, Network or any third party authorized herein.
I represent and agree that I have the full right and authority to enter into this Authorization and to grant all rights hereunder. A photocopy of this Authorization is as valid as the original. I have been advised that I am entitled to receive a copy of this Authorization.
Patient’s PRINTED Name:
Patient’s Date of Birth:
Patient’s Social Security Number:
CONSENT OF PARENT OR GUARDIAN(TO BE SIGNED IF PERSON SIGNING ABOVE IS UNDER 18)
I represent and warrant that I am the parent or guardian of the above-signed minor (“Minor”). I have read the foregoing Authorization and am familiar with all of the terms and conditions thereof and I consent to its execution by the Minor. I agree to indemnify and hold Producer, Network, Practitioner, and Licensee and Assigns, harmless from and against any and all claims, liabilities, costs or expenses, including reasonable attorney’s fees which may arise from the breach or alleged breach by the Minor or me of the foregoing Authorization or this agreement.
Signature of Parent/Guardian: