Healthcare Media Consent Form

HEALTHCARE MEDIA CONSENT FORM

I, Patient Name: , born on: , hereby authorize the facility named below to create and use audio, photographic, video and/or written records of my image and/or voice as described in this authorization.

Patient Information

Insurance Information

Medical History (Brief)

Consent for Media Capture and Use

I authorize the facility: and its authorized agents to make the following types of media recordings (check all that apply):

Photography    Video Recording    Audio Recording    Written or Transcribed Statements    Other:

I authorize the facility to use my media for the following purposes (check all that apply):

Inclusion in my medical record or treatment documentation    Clinical education and training of health professionals
Institutional marketing, brochures, publications, or presentations    Research, professional journals, or conference presentations
Internal quality improvement and risk management    Other:

Authorization Duration: This authorization will expire on , unless earlier revoked in writing. If no date is provided, this authorization remains in effect until revoked.

Legal Terms and Acknowledgments

I understand that media created pursuant to this authorization may be reproduced, distributed, transmitted, or displayed in various media formats and may be edited or modified. I release and hold harmless the facility, its employees, agents and licensees from any claims for invasion of privacy, defamation, or any other claim arising out of the authorized use of such media, to the extent permitted by law.

I understand that I will not receive financial compensation for the creation or use of the media, unless otherwise agreed in writing. I understand that I may revoke this authorization at any time by delivering a written notice to the facility; such revocation will not apply to uses already made pursuant to this authorization prior to receipt of the revocation.

I understand that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization except where permitted by law.

I acknowledge that the facility's privacy practices apply to any medical information captured in the media and that I have been provided with (or have had the opportunity to request) the facility's privacy practices and notice of patient rights.

Special Circumstances

If the patient is a minor or legally incapable of providing consent, this form must be signed by a parent or legal guardian. Indicate if signing on behalf of a patient: Patient is a minor or Patient is legally incapacitated

Acknowledgment

I acknowledge that I have read and understand this authorization, that the information requested is voluntary, and that I have had the opportunity to ask questions and receive answers about the uses and disclosures permitted by this document.

By signing below I certify that I am the patient or I am authorized to act on behalf of the patient and that my signature is valid and binding.

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