Healthcare Image Agreement

HEALTHCARE IMAGE AGREEMENT

Patient Name:    Medical Facility/Provider:    Date of Birth:

Patient Information

Emergency Contact

Insurance Information

Medical History (Brief)

Description of Images

Type(s) of image to be created: Photographs Video recordings Radiographic/diagnostic imaging 3D scans/models

Body part / area to be imaged:    Date of capture (if known):

Authorization for Use

I hereby authorize the Medical Facility/Provider listed above to create and use the images described herein. I grant permission for the images to be used for the following purposes (select all that apply):

Treatment and medical record documentation
Diagnostic review and consultation
Professional education and training
Professional publication or presentation
Marketing, advertising, or website use
Quality assurance and peer review
Research (subject to applicable approvals)
Other:

Rights, Limitations and Privacy

Ownership and Use: I understand that the Medical Facility/Provider retains ownership of the images and any derivative works. I grant a perpetual, royalty-free, worldwide license to the Medical Facility/Provider to use, reproduce, edit, publish, distribute and display the images for the uses I have authorized.

Third-Party Disclosure: I acknowledge that images may be shared with consultants, other healthcare providers, third-party contractors engaged by the Medical Facility/Provider for permitted uses, and where required by law. I understand that identifiers will be removed where feasible for uses not related to my direct care.

Compensation: I understand that I will not receive financial compensation for the creation or permitted uses of the images unless otherwise agreed in writing.

Revocation: I may revoke this authorization at any time by delivering a written notice to the Medical Facility/Provider. Revocation will not apply to uses already made in reliance on this authorization prior to receipt of the revocation. Certain uses (for example, placement in the permanent medical record or material already published) cannot be rescinded.

Expiration: This authorization expires on: . If no date is provided, this authorization will remain in effect until revoked as described above.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been informed of how protected health information (PHI) contained in the images will be used and disclosed pursuant to this authorization. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

I understand that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on my signing this authorization except where allowed by law. I further understand that if I do not sign, the Medical Facility/Provider may decline to capture non-essential images requested for uses outside my direct clinical care.

By signing below I certify that I have read and fully understand the terms of this Healthcare Image Agreement, that I am the patient or am authorized to act on behalf of the patient, and that I consent to the uses described above.

I affirm the following by checking the box: I have read and understand this authorization and authorize the uses selected above.

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