Tell Us Your Story of Care

Every day, our dedicated staff provide hands-on, expert care to New Yorkers who need it. Tell us about your VNSNY story of care.

• I am a...*
  CaregiverPatientPatient's RelativeMedical ProfessionalVNSNY EmployeeOther
• Care was provided by*
  NurseHome Health AideSocial WorkerPhysical TherapistOther
• *
• Email*
• First Name*
  First
• Can we contact you regarding your story?*
  One of our editors may reach out to you in order to discuss your story and possibly publish it. Your identity will remain fully confidential and will not be shared.
  • Yes
  • No
• Consent to use my story*
  I hereby authorize VISITING NURSE SERVICE OF NEW YORK (VNSNY), its affiliates and their respective licensees, successors and assigns, the right without limitation and in perpetuity, to use, record and publish my first name (last name will not be published), and the content submitted in this form or content agreed upon after interviews with VNSNY editorial staff (“Publications”), which may include health information about me and which may be considered protected health information (“PHI”) under the Health Insurance Portability and Accountability Act, Privacy Rule or under state law. Such material may be used in advertising and promotion of VNSNY and for fundraising purposes in any medium existing now or hereinafter created (such as newspapers, television or radio).
  
  I agree that all Publications of me and/or the story used and/or taken by VNSNY and all rights therein and thereto, including all copyrights, trademarks, and all other tangible and intangible rights, shall be owned by VNSNY, and VNSNY shall be entitled to use, assign, or otherwise exploit the Publications in any manner and in all media, now existing or subsequently developed, throughout the world in perpetuity. If I should receive any print, negative or other copy of the Publications, I shall not authorize use of the same for any commercial purpose nor authorize its use by anyone else.
  
  Nothing herein will constitute any obligation on the part of VNSNY to make any use of the Publications or the rights set forth herein.
  
  I will make no financial claims for the use of the Publications. VNSNY will not condition treatment, payment, enrollment or eligibility for benefits on whether you sign this authorization.
  
  I can revoke this authorization at any time before VNSNY has relied upon it, but VNSNY may use and disclose this information to the extent VNSNY has relied upon the authorization, which may occur after VNSNY prepares work product from the information received by me. Once that occurs, it is not possible to revoke my authorization.
  • By checking this box I accept the terms outlined above
• Name
  This field is for validation purposes and should be left unchanged.