Authorization For Use Or Disclosure Of Patient Photographic and/or Video Images

Please correct the errors described below.

Authorization:

I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by the practice listed below. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations.

Purpose:

The photographic/video images. and/or testimonial will be used for: Social Media and/or Advertising

Revocability:

I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed.

No Treatment Conditions:

I understand that the practice cannot condition treatment on whether or not I sign this authorization.

DISCLAIMER: By typing your name, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

If Personal Representative

DISCLAIMER: By typing your name, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

If Patient is a Minor

DISCLAIMER: By typing your name, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

Loading...