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By selecting “ Approve”, you acknowledge that you have read, understood, and accepted this authorization and consent to the use of submitted photos as described above.*

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By submitting photographs, videos, or other media (“Content”) to Smoky Mountain Home Health & Hospice for use in memorial services, tribute displays, printed materials, social media, websites, or related hospice remembrance activities, you acknowledge and agree to the following:

I certify that I am the patient, legal representative, family member, or otherwise authorized individual with permission to submit the Content and grant Smoky Mountain Home Health & Hospice permission to use, reproduce, display, and share the submitted Content for memorial and tribute purposes.

I understand that photographs and identifying information may be considered protected health information under the Health Insurance Portability and Accountability Act (HIPAA). By signing this agreement, I voluntarily authorize Smoky Mountain Home Health & Hospice to use the submitted Content in connection with memorial services and remembrance activities.

I understand the submitted Content may appear in:
Memorial services or celebration of life events
Printed tribute materials
Digital slideshows or presentations
Internal remembrance displays

I understand that submitting Content is completely voluntary and refusal to provide authorization will not affect any care, services, or benefits.

I release and hold harmless Smoky Mountain Home Health & Hospice, its employees, staff, and representatives from any claims related to the authorized use of the submitted Content.

I have read and understand this authorization.
 I certify I have authority to submit these photographs/media.
 I authorize Smoky Mountain Home Health & Hospice to use the submitted Content for memorial and tribute purposes.

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Memorial Photo Upload

Memorial Photo Upload

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