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Share a
Success Story!

Have you recently experienced a positive outcome you would like to share? If a Care Manager, PHP team member, or service provider has impacted or improved a member’s quality of life, please tell us below who you would like to highlight and how they made an impact on a PHP member.

Stories may be featured in PHP email newsletters, the website and on social media.

Please note: Your name and email address are required for security purposes only and will not be used in your submission or to contact you.
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Partners Health Plan Media Release and Authorization

By signing this form, I understand that I am providing consent and authorization for Partners Health Plan to take and use photo imagery, audio, video image, and/or testimonial (with or without the use of the person’s first name) in perpetuity. This will allow Partners Health Plan to take and use photo imagery, audio, video image, and/or testimonial for internal or external communications for the purposes of education, advertising, marketing, publicity, and/or fundraising. Use could include distributing materials on the website, in email newsletter, social media, TV, radio, news releases for the media, and/or print publications such as newspapers, magazines, and Partners Health Plan publications (brochures that are provided to the general public). I also give permission, if interviewed, by Partners Health Plan or its affiliates to use the story, and any of the direct quotes in any medium, including descriptive details that individual chooses to share about their life with Partners Health Plan.

By signing this form, I understand and agree to the following:

1. Giving consent will publicize that services are provided to the individual by Partners Health Plan.

2. Partners Health Plan will retain all rights to the photographs, moving images, sound recordings, and other media, and that there will be no compensation by Partners Health Plan.

3. I waive any right to inspect or approve media that contains my name, image, sound recordings, story, and/or information.

4. I will not assert any claim of any nature against Partners Health Plan, its employees and agents, and/or affiliate programs relating to the exercise of the permissions granted by this Release and Authorization.

5. I understand and acknowledge that the Internet allows for wide sharing and forwarding of information and that PHP cannot control all reproduction and/or re-disclosure of information.

6. The photo imagery, audio, video image, and/or testimonial obtained during the period of this authorization may be utilized indefinitely. This authorization will remain in effect until the person supported by Partners Health Plan (identified above) is discharged at which time no new photos, audio, video or testimonials obtained from that date forward may be used.

7. I may revoke this Release and Authorization at any time, in writing, but a revocation, or discharge, will not impact any use or disclosure made prior to the date the revocation is received or discharge has taken effect.

8. I understand that I have read this document (or it has been translated to me), I fully understand it, and my consent is made knowingly and voluntarily. I am signing this Release and Authorization voluntarily and understand that provision of services to me by Partners Health Plan and/or its affiliate programs is not conditioned on whether or not I sign it.

How can we assist you?

Contact Partners Health Plan for current member assistance, to learn more about becoming a PHP member, or for general questions and inquiries.

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