Healthcare PECA Capture App

Healthcare PECA Capture App

This Healthcare PECA Capture App Consent and Authorization ("Authorization") documents the patient’s informed consent for the capture, storage, access, and permissible disclosure of protected health information captured through the Provider Electronic Capture Application ("PECA"). Patient Name: ; Date of Birth: .

Patient Information

Insurance Information

Medical History

Capture Details and Consent

I authorize the capture of the following types of data during my clinical encounter (check all that apply):

Clinical Photographs (still images)

Video Recording

Audio Recording

Sensor/Data Feed (e.g., device telemetry)

Legal Notices, Risks and Rights

I understand that captured images, audio, video, and sensor data constitute protected health information. The data will be used for the purposes stated above. Reasonable technical and administrative safeguards will be used to protect the data, but no method of transmission or storage is completely secure. There is a risk of unauthorized access or disclosure. I consent despite this risk.

I understand that this Authorization permits the capture and limited disclosure set forth herein. The data may be shared with members of my care team, designated third‑party service providers who support the PECA platform, and others as required for treatment, payment, or healthcare operations. Redisclosure by recipients may be subject to separate protections but cannot be fully controlled by the capturing provider.

I understand that I have the right to withdraw this Authorization at any time by submitting a written revocation to the provider identified below. Withdrawal will not affect any actions taken in reliance on this Authorization prior to receipt of the revocation. In some circumstances, withdrawal may limit the provider’s ability to document care using the PECA platform.

HIPAA Acknowledgment

By checking the box below I acknowledge that I have received or been offered the provider’s privacy practices notice and understand my rights regarding my protected health information.

I acknowledge receipt of the provider's privacy notice and my HIPAA rights.

Authorization and Signature

I hereby authorize the capture, use, storage, and disclosure of my protected health information as described in this Authorization for the purposes stated above. I understand that signing this Authorization is voluntary and that treatment, payment, enrollment, or eligibility for benefits is not conditioned on my signing this Authorization except as permitted by law.

If the signer is not the patient, indicate your relationship to the patient and your authority to sign (e.g., parent, guardian, healthcare proxy):

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