Healthcare Photo Medical Form

Healthcare Photo Medical Form

Patient Name:    Date of Birth:

Patient Information

Insurance Information

Medical History (Brief)

Photographic / Video Authorization

I hereby authorize the healthcare facility, its staff, agents, contractors, and authorized representatives to take and use photographs, digital images, video recordings, and other visual media (collectively, "Images") of me for the purposes selected below. I understand that Images may include identifiable health information and are protected under applicable privacy laws.

Purpose(s) for which Images may be used (check all that apply):

  Treatment, clinical documentation and medical record maintenance
  Educational presentations and professional training
  Research and quality improvement (with or without de-identification)
  Publication in journals, textbooks, or professional materials
  Marketing, public relations, and promotional materials
  Other:

Permitted uses and disclosures (select one):

  Images may be used with my name or other direct identifiers included
  Images may be used only after removal of direct identifiers (de-identified)

I understand that Images may be reproduced, edited, cropped, transmitted, published, and stored in electronic and hard copy records. The facility may transfer Images to third parties for the approved purposes identified above. I understand that once released to third parties, the facility may not be able to control subsequent use or disclosure of Images.

Authorization Terms, Expiration and Revocation

This authorization is valid until: . If no date is entered, this authorization will remain in effect until revoked.

I may revoke this authorization at any time by delivering written notice to the facility's privacy officer or designated contact. Revocation will not affect uses or disclosures made in reliance on this authorization prior to receipt of the revocation.

HIPAA Authorization & Patient Acknowledgement

I authorize the release of protected health information (PHI) about me in the form of Images and related clinical information for the purposes described above. I understand that once PHI is disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and therefore may no longer be protected by federal privacy regulations.

I understand that: (a) my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization; (b) I may inspect or copy the PHI to be used or disclosed as described in this authorization; and (c) I may revoke this authorization at any time as described above.

I acknowledge that I have read and understand this authorization and that I am signing it voluntarily.

Certification: By signing above I certify that I am the patient or I am authorized to act on behalf of the patient. I further certify that the information provided on this form is true and correct and that I have been given the opportunity to ask questions regarding the use and disclosure of Images.

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