Nemours Photo Consent - Dunkin Prom 2025

Authorization to Disclose Patient Photo/Video/Audio or Other Protected Health Information (PHI) for Publication:
Patient Name*
DOB*
MRN
Are you currently or have you ever been a patient of Nemours Children’s Health?

YESNO
Name* , on behalf of the above-named patient, authorize Nemours Children’s to USE AND/OR DISCLOSE the above-named patient’s information and story with media outlets, social media channels and networks, advertising, websites, public marketing, promotional materials, fundraising, training and/or presentation and other similar venues. This form is not intended for the use of requesting copies of the patient’s medical record. Such requests are to be directed to the local Health Information Management department.
The following people and/or media organizations will have access to the PHI authorized in #1 above:

Online and printed publications for Nemours Children's Health and Nemours social media accounts and external third-party media outlets; and Dunkin' Joy In Childhood Foundation online and printed media.
3.This authorization will expire*

On a specific date (if checked, enter the date)After the completion of the following event/service/project10 years from date this form is signed.
Type of release

Photo/Video/Audio
On a specific date (if checked, enter the date)

MonthDayYear
Date
I understand that:
- Nemours Children’s will not condition treatment on whether I authorize the requested use or disclosure.
- I can change my mind and revoke this authorization, in writing, at any time, by sending a written revocation to the Nemours Children’s Privacy Officer at 10140 Centurion Parkway North, Jacksonville, Florida 32256.
  - If Nemours Children’s has already used or disclosed the protected health information described above, then the revocation will only be valid for future uses or disclosures.
- Information used or disclosed may be redistributed by the recipient and may no longer be protected by Federal or state confidentiality law. It is common that disclosures for broadcast or publication will include posting the materials onto web, social media or similar sites. Once this occurs your information will be publicly available and freely distributed.
- I have the right to inspect or copy the protected health information to be used or disclosed, as permitted under Federal law or state law, to the extent the state law provides greater access rights
- I will receive a copy of this Authorization.
Date

MonthDayYear
Date
Signature of Patient or Legal Guardian

Clear
Print Name of Patient or Legal Representative
Email Address
example@example.com
Cell Phone
Purpose of photo/video:Promote Nemours Prom Events
Situation in photo/video:Nemours Prom 2025
Patient’s gender : Male | Female | Nonbinary | Prefer not to answer
Patient description in photo/video (hair color, clothing):_____
___________________________________________________
Name of staff person:Melissa Nicely
Department:Child Life, Creative Arts Therapy & School Programs
Location:Nemours Children's Health, Delaware
Specific location in hospital or clinic in photo/video: Cafeteria
Date photo/video taken: June 7th, 2025
Nemours Children’s includes: The Nemours Foundation, a Florida not-for-profit corporation, its operating divisions and sites, and its affiliates and subsidiaries, including Nemours Children’s Hospital, Delaware, Nemours Children’s Hospital, Florida, Nemours Children’s Hospital, Surgery Center, Bryn Mawr and Nemours Children’s Hospital, Surgery Center, Deptford; and all entities operating under the name Nemours Children’s Health.

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