Healthcare Interviewee Release Form

Healthcare Interviewee Release Form

Interviewee Name:    Date of Birth:

Patient Information

Insurance Information

Medical History (Relevant to Interview)

Interview Details

Interview Date:    Location:

Audio recording
Video recording
Photographs / Stills
Written notes / transcript

Clinical education and training
Research and publication (with/without identifiers as indicated)
Quality improvement and internal review
Publicity, marketing, or media

No compensation will be provided
Compensation provided as described:

Consent and Release

I, the undersigned interviewee, hereby authorize the interviewer and the interviewer’s agents, assigns, successors, licensees, and designees (collectively "Authorized Parties") to record, photograph, videotape, transcribe, and otherwise document my verbal statements, image, likeness, and/or medical testimony in connection with the above-described interview and to use such materials for the Permitted Uses indicated above. I grant to Authorized Parties a perpetual, worldwide, royalty-free, transferable, and sublicensable right to reproduce, distribute, publicly display, publish, create derivative works from, and otherwise exploit such materials.

I acknowledge and agree that Authorized Parties may edit, excerpt, combine, and adapt recorded materials and that I will not receive any further payment, approval rights, or review of finished materials unless explicitly stated in writing. I release, indemnify, and hold harmless Authorized Parties and their employees, officers, agents, and contractors from any claims, demands, or causes of action arising out of the use of the materials as permitted herein, including claims of defamation, invasion of privacy, or infringement of moral rights.

I understand that I may revoke this authorization in writing at any time, but that revocation will not apply to uses or disclosures already made prior to receipt of written notice. To revoke this authorization, I must provide written notice to the contact person identified below; Authorized Parties will make reasonable efforts to cease future uses but cannot withdraw materials already published or disseminated.

HIPAA / Privacy Authorization

I authorize the disclosure of my protected health information that is included in the interview materials to the Authorized Parties for the purposes described in this form. I understand that once my protected health information has been disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and no longer protected by applicable privacy laws. This authorization is voluntary and is not a condition of providing treatment, payment, enrollment, or eligibility for benefits.

Expiration: This authorization will expire on the date indicated below, or, if no date is provided, five years from the date of my signature. I understand I may specify an earlier expiration date.

Expiration Date:

Certifications

By signing below I certify that I am the person named above, that I am at least 18 years of age and competent to execute this release, or that I am the legal guardian or personal representative with authority to sign on behalf of the interviewee. I acknowledge that I have read and understand this form, that all my questions have been answered, and that I have received a copy of this form upon request.

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