Healthcare Video Consent Form

HEALTHCARE VIDEO CONSENT FORM

Facility/Provider Name:    Date:

Patient Information

Date of Birth:    Gender:

Primary Phone:    Email (optional):

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History (Relevant)

Purpose and Scope of Recording

I authorize the Facility/Provider named above to make audio, video, and/or photographic recordings of me for the purposes indicated below. I understand that unless I limit consent below, recordings may include identifiable health information and images.

Types of recording to be made (check all that apply):
Video recording    Audio recording    Still photographs

Permitted uses (check all that you consent to):
Clinical care and treatment documentation
Quality improvement and provider training
Educational purposes (internal & academic)
Marketing, public relations, or promotional materials

Risks, Benefits and Alternatives

I understand that potential benefits include improved documentation of care, enhanced education for clinicians, and contribution to research or education. Potential risks include loss of privacy if recordings are improperly disclosed. The Facility/Provider will use reasonable administrative, technical, and physical safeguards to protect recordings, but no security measure is absolute.

I understand that I may decline or limit consent without affecting my right to receive treatment, payment, enrollment or eligibility for benefits. I understand that if I agree to use for marketing, I may revoke that part of the authorization, as described below.

HIPAA / Privacy Acknowledgment

I acknowledge that recordings may contain my protected health information. The Facility/Provider will use and disclose such information in accordance with applicable privacy laws. I understand who may access the recordings for the purposes I have authorized and that certain disclosures (for example, to other providers involved in my care) may be made without additional authorization.

I acknowledge that I have read and understand the privacy implications described above.

Authorization Period and Revocation

This authorization is valid until: or until revoked in writing. To revoke this authorization, I must deliver a written notice to the Facility/Provider at the address below. Revocation will not apply to disclosures already made in reliance on this authorization prior to receipt of the revocation.

Consent Selection

By checking the box below I provide authorization for the specific uses I have selected above and certify that I understand the terms of this authorization.

I authorize the Facility/Provider to record and use my images/audio for the purposes indicated on this form.

I understand that I will not receive payment or remuneration for use of my recordings and that the Facility/Provider may retain copies for its records and legitimate uses consistent with this authorization.

If Signer Is Authorized Representative

If you are signing as a parent, legal guardian, healthcare agent, or other authorized representative, provide your relationship and authority to act for the patient.

Relationship to Patient:    Representative Phone:

Certification and Signature

By signing below I certify that I have read and understand this authorization, that the information I have provided is true and accurate to the best of my knowledge, and that I have had the opportunity to ask questions. I understand I may receive a copy of this authorization upon request.

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