HIPAA Auth Form 4564 042916
AUTHORIZATION FOR PATIENT PHOTOGRAPHY, RECORDINGS AND/OR INTERVIEWS
I authorize this release of personal health information by Corewell Health William Beaumont University Hospital, Oakwood Healthcare and Botsford Hospital (“Corewell Health”) and/or any of its divisions, affiliates or agents based on the following conditions:
- This release/authorization applies to protected health information in the form of photographs, audio, video, digital and film recording of me, my minor child, and/or another person for whom I am legal representative.
- These images or written materials become the property of Beaumont, the news media or other parties to whom they are released, including copyright.
- I release Beaumont Health or any of its divisions, affiliates, medical staff, employees or agents from any and all liability including any claims of libel or invasion of privacy connected with or resulting from these images or written materials. I understand that I am not required to sign this form and refusing to sign will not affect my care. I have the right to stop recording or interviewing at any time.
- I understand that news media and other third parties are not covered by federal privacy regulations and that the information described above will likely be re-disclosed and no longer protected by the federal privacy regulations or State law.
- This release is given without promise of compensation or royalties.
I agree to the following:
- Take and/or publish photographs or audio/videotape recordings of me and/or my minor child and/or other person, for whom I am the legal representative.
- Interview, disclose and/or publish information about me and/or my minor child or other person for whom I am the legal guardian about care as a patient at Beaumont Health, including diagnosis, nature and/or extent of injuries or illness.
- The photographs, audio/video recordings and/or information can be used in:
Internal or external publications, including news releases, websites and social media Advertising, marketing or fundraising materials
- Allow the news media or other third parties to interview, take photographs or recordings and publish or broadcast (without right of review) personal health information regarding care provided to me and/or my minor child, and/or another person for whom I am the legal representative.
This authorization is effective until revoked in writing by the undersigned. Such revocation will only prevent any future use of the images or written materials. Send a written revocation to: Corewell Health Corporate Privacy Officer, 28050 Grand River Ave., Farmington Hills, MI 48336.
A copy of this form will be provided upon request.