I understand that the PHI to be disclosed includes my child’s first and last name, and city and state of residence, as well as my child’s picture. This disclosure is being made at my request. This authorization shall remain in effect upon submission of the entry and shall remain in effect until 2029. I specifically understand that copies of the 2022 baby calendar may be distributed to the public throughout 2022. I also understand the calendar information may be distributed using other marketing methods. I understand that I may revoke this authorization at any time (except to the extent that action, such as publication of the calendar, has been taken in reliance on it) by mailing or hand delivering written notification to the following person:
Privacy Officer, NMRMC
P.O. Box 426
Chanute, KS 66720
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