Healthcare Artwork Release Consent

HEALTHCARE ARTWORK RELEASE CONSENT

Patient Name:    Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History (Relevant)

Artwork Description

Title:    Date Created:

Authorization and Rights Granted

I, the undersigned Patient or Legal Representative, hereby grant to the Facility, its affiliates, successors, licensees and assigns a non-exclusive, royalty-free, worldwide, perpetual right and license to reproduce, publish, publicly display, distribute, transmit, and otherwise use the Artwork described above in whole or in part, and to create derivative works for the following purposes:

The Artwork may be used for clinical education, research, internal and external training, promotional materials, printed publications, digital and social media, and facility exhibitions, subject to the conditions stated in this form.

Privacy, Identifiable Health Information, and HIPAA

The Facility will not intentionally disclose protected health information that identifies the Patient in connection with reproduction of the Artwork unless the optional authorization below is expressly granted. Authorizing use of identifiable health information is separate from and in addition to this Artwork Release Consent.

Compensation, Ownership, and Use Limitations

Patient understands and agrees that no payment, fee, or other compensation will be made in exchange for the rights granted herein. Ownership of the original Artwork remains with the Patient unless otherwise agreed in writing; however, the Facility may retain copies and reproductions. Patient hereby waives any moral rights to the extent permitted by law for use described herein.

Revocation and Expiration

This authorization will remain in effect until: or until revoked in writing by the Patient or Legal Representative. Any revocation will not apply to actions already taken in reliance on this authorization prior to receipt of revocation.

Certifications and Acknowledgments

By signing below, I certify that I am the Patient or am authorized to act on behalf of the Patient as the Patient's legal representative. I have read and understand the contents of this Artwork Release Consent. I understand that I may refuse to sign or may revoke this authorization at any time by providing written notice, subject to the limitations described above. I acknowledge that questions regarding this form have been answered to my satisfaction.

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