Consent for use of medical imagery
Medical Imagery (still photographs, video of your body and/or audio recordings) may be taken of you while you are undergoing evaluation and/or treatment. This imagery may become a part of your medical record. As part of your medical record, your privacy concerning this imagery is protected by the Privacy Act of 1974 (title 5, United States Code, section 552a), Public Law 104-191, the Health Insurance and Portability and Accountability Act of 1996. This imagery procedure is used to assist with medical decision making. STARS Plastic Surgery also seeks your consent to use the imagery for additional purposes such as but not limited to education, medical examinations or certifying boards, medical publications and materials to educate other patients with similar problems or interested in a similar procedure. I hereby grant permission for the use of any of my medical records including illustrations, photographs or other imaging records created in my case, for use in examination, testing, credentialing, and/or certifying purposes by The American Board of Plastic Surgery, Inc. This imagery may have identifying marks or features unrelated to your condition. I understand that I can request, that any time, that the recording or filming be stopped. I also understand that I can revoke my consent at any time in writing to STARS Plastic Surgery. Withdrawing my consent will apply to recordings or filmings from that point onwards but will not impact any videos or imagery previously published. I understand that I will not be compensated for use of my imagery.