Healthcare Photo Release

HEALTHCARE PHOTO RELEASE

Patient Information

Patient Name:

Date of Birth:     Medical Record/ID #:

Emergency Contact

Insurance Information (Optional)

Description of Photographic Material

I authorize the capture, use and disclosure of the following types of photographic, video, or digital images:

Permitted Uses (check all that apply)

Treatment and clinical care within this facility and other treating providers Professional education and training (medical, nursing, allied health) Research and quality improvement (may appear in publications or presentations) Facility marketing and promotional materials, including print and electronic media Facility social media channels Other:

Privacy, HIPAA & Identifiability

I understand that photographic material may contain personally identifiable information. I authorize the use described above:

May include identifying information (name, face, unique marks) May only be used if de-identified (no name, face, or other direct identifiers)

Duration and Expiration

This authorization is effective on the date signed below and will expire on:     Perpetual (no expiration)

Authorization, Release and Limitations

By signing below I authorize the facility and its representatives to create, use and disclose the photographic material specified above for the permitted uses checked. I understand and agree that:

1. I release the facility, its employees, officers and agents from liability for any claims arising out of the authorized use, distribution, or publication of the photographic material, except to the extent prohibited by law.

2. No financial compensation is required or expected for the creation or authorized use of the photographic material unless otherwise agreed in writing in a separate document.

3. I may revoke this authorization at any time by providing a signed written notice to the facility's privacy official. Revocation will not affect uses or disclosures already completed in reliance on this authorization prior to receipt of the revocation.

4. The facility will take reasonable measures to protect my privacy in connection with the use and disclosure of photographic material, but I understand that absolute confidentiality cannot be guaranteed for some uses (for example, widely distributed marketing materials or published professional articles).

5. If the photographic material is created or used for research or publication, de-identified images will be used whenever feasible. If identifiable information is required, I will be so informed and must expressly permit that use here.

Revocation and Contact for Withdrawal

To revoke this authorization, submit a signed written revocation addressed to the facility representative listed below. Revocation will be effective upon receipt, but will not apply to disclosures already made with my prior authorization.

Additional Authorizations and Special Instructions

Certification

I certify that I am the patient named above or I am the legally authorized representative of the patient. I have read and understand this authorization, and I have had an opportunity to ask questions and receive answers about the uses described herein.

If signing as a legal representative, indicate relationship and authority to act on behalf of the patient.

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