Consent to Photograph and Authorization for Use or Disclosure

I hereby consent to be photographed while receiving treatment at the hospital. The “term” photograph includes video or still photography, in digital or any other format, and any other means of recording or reproducing images.

I hereby authorize the use of the photograph(s) by, or disclosure of the photograph(s) to:

Pomona Valley Hospital Medical Center 1798 N. Garey Ave Pomona, CA 91767

I hereby authorize the use or disclosure of the photograph(s) for the following uses or purposes (describe permitted uses, e.g., dissemination to hospital staff, physicians, health professionals, and members of the public for educational, treatment, research, scientific, public relations, marketing, news media, and charitable purposes):

I consent to be photographed and authorize the use or disclosure of such photograph(s) in order to assist scientific, treatment, educational, public relations, marketing, news media, and charitable goals, and I hereby waive any right to compensation for such uses by reason of the foregoing authorization. I and my successors or assigns hereby hold the hospital, its employees, my physician(s), and any other person participating in my care and their successors and assigns harmless from and against any claim for injury or compensation resulting from the activities authorized by this agreement.

EXPIRATION

This Authorization expires (           ): Upon expiration of this Authorization, this hospital will not permit the further release of any photograph, but will not be able to call back any photographs or information already released.

 MY RIGHTS

I may request the cessation of filming or recording at any time. I may rescind this Authorization up until a reasonable time before the photograph is used, but I must do so in writing and submit it to the following address:

HIM Department 1798 N. Garey Ave Pomona, CA 91767

I may inspect or obtain a copy of the photograph whose use or disclosure I am authorizing. I may refuse to sign this Authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits. I have a right to receive a copy of this Authorization. Information disclosed pursuant to this Authorization could be re-disclosed by the recipient. Such re-disclosure is in some cases not protected by California law and may no longer be protected by federal confidentiality law (HIPAA). I understand that I will not receive any financial compensation.

(Patient/representative/spouse/financially responsible party)

If signed by someone other than patient, indicate relationship:

(Patient/representative/spouse/financially responsible party)

Reference: California Hospital Association Consent Manual 2014