Share your story.

Carilion Clinic would like your permission to use your story as a current or former patient, as a member of the community, or as a Carilion Clinic employee or volunteer. If you agree to the terms listed below, please click "agree" at the end of this page.

1. I hereby authorize members of Carilion Clinic's workforce to use and disclose protected health information as noted below. I understand that any of the following PHI may be used/disclosed:
   • Name
   • Hometown
   • My likeness
   • My diagnosis or treatment history
   • Other
2. Carilion Clinic would like your permission to use your story as a current or former patient, as a member of the community, or as a Carilion Clinic employee or volunteer. If you agree to the terms listed below, please click "agree" at the end of this page.
   
3. I understand that any disclosure of my protected health information has the potential for an unauthorized re-disclosure of my health information.
   
4. I understand that I may cancel this authorization in writing at any time except to the extent that Carilion Clinic has already relied on this authorization. For example, if the article has already gone to press or a video has already been made based on this authorization, Carilion Clinic will not be able to stop the release.
   
5. I understand that I may cancel this authorization by sending or faxing a written noticed to the department listed below stating my intent to cancel this authorization.
   • Carilion Clinic Strategic Development
   • 711 S. Jefferson St.
   • Roanoke, VA 24016
6. I understand that Carilion Clinic may not condition my treatment, payment, enrollment in a health plan or eligibility for benefits on the provision of this authorization.