Authorization to Release Photographs

 

Patient’s name: _____________________________________ Date of birth: _________

 SSN: _______________________ Previous name: _____________________________

 Doctor’s Name __________________________________________________________

 Practice Name: __________________________________________________________

 

I authorize the above listed doctor and practice to release any and all photographs taken of the patient named above for the following uses:

 

            ___ Educational Journals

             ___ Teaching purposes

             ___ Website

             ___ Other _________________________________________________________

This request and authorization applies to photographs taken for the following treatment, condition, or dates of treatment:

______________________________________________________________________

______________________________________________________________________                                                                                                                     

THIS AUTHORIZATION EXPIRES ON                                           or _________ DAYS AFTER

THE DATE IT IS SIGNED; or WHEN THE FOLLOWING EVENT OCCURS _____________

_________________________________________________________________________

 

I may cancel this authorization to the extent allowed by law.  If I do, I understand that the doctor or practice may have already released information about me after I gave permission.  I know that canceling this authorization would not prohibit any release of photographs by the doctor or practice in reliance on my original authorization.

 

To cancel this agreement, I must:

  •  Write a letter to the doctor or practice advising of my wish to cancel my authorization to disclose photographs taken of me by this practice.  I (or my authorized representative) must sign and date the letter.
  •  Once my doctor gives out any photographs I have approved, I know that my doctor has no control over them.  Federal or state privacy laws may no longer protect the information.

 ________________________________________________________________________

Signature of patient or patient’s authorized representative                            Date signed

 ________________________________________________________________________

Relationship or status if signed by parent, legal guardian, personal representative, etc.