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
___ 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.