HIPAA-Compliant Photo Release Form

HIPAA-Compliant Photo Release Form

We love watching your family grow. If you'd like us to share your baby's photo on our website, Facebook, or Instagram, upload it below. You choose what we include, and you can ask us to remove it at any time. Authorize the use and upload of your photo in accordance with HIPAA regulations.
Parent or Guardian Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Name

First NameLast Name
Please upload your photo

Cancelof
Where Can We Share?
Authorization and Release

Authorization to Use and Disclose Photo and Related InformationBy signing below, I give Southern Illinois OB-GYN Associates permission to use and share the photo or photos I have uploaded, along with any name, birth date, caption, or provider information I chose to include above.
1. What is being shared. Only the photo or photos I uploaded and the details I provided in this form will be shared. Nothing from my medical record will be included.
2. Where it may be shared. The photo may appear on the SI OB-GYN website, Facebook page, and Instagram account, on the platforms I selected above.
3. Why it is being shared. SI OB-GYN uses these photos to celebrate patients and their families and to help other expecting families learn about the practice.
4. Public visibility. Once a photo is posted on the website or on social media, it becomes publicly visible. Other people may save, share, repost, or comment on it. SI OB-GYN cannot control what happens to the photo after it is shared and cannot recover copies that others have downloaded or reshared.
5. No requirement to sign. Sharing a photo is completely voluntary. My care at SI OB-GYN will not be affected in any way by whether I sign this form or not.
6. No payment. I understand I am not being paid for the use of the photo and am not entitled to compensation if the photo is shared.
7. My right to revoke. I can ask SI OB-GYN to stop using the photo at any time by emailing hhudson@siobg.com or by calling 618-998-8808. SI OB-GYN will remove the photo from any platform it controls within a reasonable time. Anything already saved, shared, or reposted by others may remain in circulation and cannot be retrieved.
8. Information shared outside HIPAA protection. I understand that once the photo and details are posted on Facebook, Instagram, or the SI OB-GYN website, they are no longer protected by HIPAA, and federal privacy law no longer applies to the information.
9. This authorization expires five years from the date signed, unless I revoke it earlier in writing.
For photos of minors: I confirm that I am the parent or legal guardian of the child shown in the photo and have the authority to give this permission on the child's behalf.
By signing below, I authorize the use of my photo as described above and acknowledge that I have read and understand the HIPAA notice regarding my rights and privacy.
Date

MonthDayYear
Date
Printed Name
Should be Empty:

HIPAA-Compliant Photo Release Form

Authorization and Release