Required Forms:


Because we respect the rights and privacy of our patients at QVMC, we require a signature on both the Photograph, Film or Vocal Recording Release form and the Release for the Use and / or Disclosure of Protected Health Information. Both require a signature by a parent / guardian, for all patients under the age of 18, or a patient over the age of 18.


Also, if your story requires that you go into any patient areas where you might see, overhear, access or temporarily possess PHI (protected health information) of a patient, you will be asked to complete an Observer Confidentiality Agreement (form is being updated) ahead of time.


+ QVMC News & Public Relations Policies

The public relations and marketing team of QVMC operates under the following guidelines and policies:


Our physicians and other caregivers are very busy. To arrange all interviews, please contact the Marketing Department. 


To protect the privacy of families and patients and uphold the law, please announce that you will be coming to the medical center. We'll find experts for interviews and rooms in which to conduct interviews. We'll also contact families upon your request to ascertain their interest in being interviewed.


To ensure patient confidentiality, privacy and sensitivity to all of the patients, families and employees at QVMC, reporters, film crews and photographers must always be accompanied by a marketing team member while on the campuses of QVMC, unless prior arrangements with the marketing staff are made.


To be photographed or videotaped at QVMC, we ask everyone to sign a Photograph, Film or Vocal Recording Release form.


To release a one-word description of our patient's condition to the media, in accordance with HIPAA, the patient must be listed in the hospital directory. (The legal guardian makes this decision at the time the patient registers.) Most health professionals in hospitals use the following terms to describe a patient's condition after a first and last name of the patient is obtained:

UNDETERMINED: Patient currently being evaluated.

GOOD: Vital signs, such as pulse, temperature and blood pressure are stable and within normal limits. Patient is conscious and comfortable; indicators are excellent.

FAIR: Vital signs are stable and within normal limits. Patient is conscious but may be uncomfortable. Indicators are favorable.

SERIOUS: Vital signs may be unstable and not within normal limits. Patient is acutely ill. Indicators are questionable.

CRITICAL: Vital signs are unstable and not within normal limits. Patient may not be conscious. Indicators are unfavorable.

DECEASED: Patient has died.








Quincy Valley Medical Center
908 Tenth Avenue Southwest  Quincy, WA 98848
Tel: (509) 787-3531  |  Fax: (509) 787-2016


Copyright 2011 © Quincy Valley Medical Center. All rights reserved.