Grateful Patient Program | Adirondack Health Foundation

Thank Your Healthcare Hero Submission Form

Name:

Would you like to remain anonymous?

Yes, I would like to remain anonymous.

No, but please only use my first name.

No, you may use my full name.

Email:

Phone:

Address:

Who would you like to honor?

Your Story

Free Text

HIPAA AUTHORIZATION FOR USE/DISCLOSURE OF INFORMATION

Opt-In

By checking this box I agree to the following electronic disclosures:

I give my permission for Adirondack Health to share my name and details of my medical care for purposes of illustrating my treatment and experience as a patient of Adirondack Health. I am not required to sign this authorization. Adirondack Health does not condition treatment, payment, benefit eligibility, or enrollment activities on the signing of this form. I can request a copy of this authorization be mailed to me. I understand that I may revoke or withdraw this permission at any time to prohibit future use of my information. To do so, I must send written notice to the Privacy Officer at Adirondack Health, 2233 State Route 86, Saranac Lake, NY 12983. By submitting a tribute through the Grateful Patient Program, you authorize Adirondack Health Foundation to share your message of gratitude with the caregiver(s) you are honoring and waive privacy rights to the enclosed information. No specific medical details will be disclosed to the caregiver you honor.

Full Name

Date of Birth:

Today's Date

Free Text

By typing your name below, you acknowledge that this electronic entry constitutes your signature and indicates your intent to sign this document electronically. You agree that your electronic signature is legally binding and has the same validity and effect as a handwritten signature.

Electronic Signature (please enter name)