The New York State Department of Health is collecting stories from enrollees who have signed up for health insurance through the NY State of Health to assist in our Outreach and Marketing initiatives. Personal stories or experiences can be very helpful in describing how consumers can apply for health insurance and how they may seek assistance in applying, if necessary.
Please note that sharing information on your personal experience in applying for insurance through NY State of Health is not a requirement. Rather, it is a voluntary opportunity for you to provide feedback on your experience that may be shared publicly.
Please also note that some of the information that you choose to share on this form may constitute “protected health information” as that term is defined in the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) privacy regulations or may otherwise be protected under applicable State or federal law.
To provide and allow us to share your story, please complete and sign sections “A” and “B” below.
hereby authorize the New York State Department of Health and any person authorized by the Department to use my personal story as outlined above, and any photograph, voice recording or video of me in printed materials and in news events and/or media campaigns, without further notice to me, for the purpose of Outreach and Marketing for the NY State of Health, Child Health Plus, or Medicaid. I understand that I will not have the opportunity to edit, review or provide further comment on my story, photograph, recording or video after it is provided. I acknowledge that I am providing this information voluntarily and that whether or not I sign the Authorization will not affect treatment, payment, enrollment or eligibility for benefits.
I understand that some of the information that I provide in this form may constitute “protected health information” as that term is defined in the federal HIPAA privacy regulations. Where the information that I provide does include protected health information, I authorize the New York State Department of Health to use and disclose this information for Outreach and Marketing purposes that are in addition to the purposes that are permitted or required by federal HIPAA regulations and/or other applicable State or federal law. I recognize that such information may be re-disclosed and no longer protected by the federal HIPAA regulations and/or other applicable State or federal law.
I acknowledge that this Authorization has no expiration date but that if at a future date I no longer want the information contained in this form, including protected health information, to be disclosed, I may revoke this Authorization and Release by contacting the New York State Department of Health in writing. However, I understand that the revocation will only be effective for future uses and disclosures of the information and not effective for uses that have already been made relying on this Authorization and Release.
I hereby agree that all materials that may include my story or experience as well as any photograph, voice recording or video shall be the property and remain the property of the New York State Department of Health and I hereby relinquish any claims to payment for my information, photograph, voice recording or video. I also understand that all such materials may be disclosed to a person who requests records from the Department under New York’s Freedom of Information Law.
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