Healthcare Post-Live Release Form

HEALTHCARE POST-LIVE RELEASE FORM

Facility Name: Department/Unit:

Patient Information

Date of Birth: Gender:

Phone: Email:

Emergency Contact

Relationship: Phone:

Insurance Information

Policy Number: Group Number:

Medical History (Relevant)

Description of Post-Live Recording

Date of Live Event: Time: Location:

Authorization and Scope of Release

I hereby authorize the Facility to use, reproduce, distribute, publish, and otherwise disclose audio and/or visual recordings and still images captured during the live event described above. This authorization specifically extends to the following uses (select all that apply):

Educational purposes (medical education, teaching presentations)
Research (de-identified or as allowed under research protocols)
Internal training and quality assurance
Marketing or promotional materials
Social media publication
Public broadcast or external distribution

I understand and acknowledge that the Facility may edit, copy, exhibit, publish or distribute these materials for the authorized uses. I understand that the materials may be shared with third parties consistent with the authorizations selected above.

Privacy, Protected Health Information and De-Identification

The recording may include protected health information (PHI). I authorize inclusion of PHI in the recording where necessary for the authorized uses: Yes No

I acknowledge that the Facility will attempt to de-identify PHI where feasible for certain uses, but de-identification cannot be guaranteed for all media. I further understand that once published or distributed, the Facility cannot always control subsequent use or redistribution by third parties.

Compensation and Benefit

I understand that I will receive compensation or not receive compensation for the use authorized herein. If compensation applies, describe amount or nature of benefit:

Duration, Revocation, and Withdrawal

This authorization shall remain in effect until: , or until revoked in writing by me. I understand that revocation will not apply to uses already made in reliance on this authorization prior to receipt of revocation.

I understand that I may withdraw this authorization at any time by providing a written notice signed by me or my legal representative to the Facility's records office. Withdrawal will not affect disclosures already made in reliance on this authorization prior to receipt of withdrawal.

Assurances and Certifications

By signing below I certify that I am the patient or the patient's legal representative and that I have the authority to grant this authorization. I acknowledge that:

• I have had the opportunity to ask questions and understand the nature and purpose of this authorization.
• My healthcare treatment, payment, enrollment, or eligibility for benefits will not be conditioned on my signing this release.
• I release the Facility, its employees, agents, and licensees from liability for use or distribution of the authorized materials consistent with this authorization.
• I understand that this authorization is voluntary and that I may request a copy of this form.

Acknowledgment of HIPAA Authorization

I authorize disclosure of my protected health information as described in this document. I understand the information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by privacy laws.

Sign Now