Cardiology Practice Photo and Video Release Authorization

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record Number: __________ Date: _________________________

Authorization

I hereby authorize [PRACTICE NAME] and its affiliated healthcare providers to take, produce, and use photographs, videos, digital images, and/or other visual recordings that include my:

• Physical appearance
• Internal cardiac imaging (e.g., echocardiograms, cardiac catheterization images)
• Diagnostic test results
• Medical procedures
• Other medical documentation: ________________________________

Permitted Uses

I understand these images/recordings may be used for:

• Medical documentation and treatment planning
• Educational purposes for medical professionals
• Quality assurance and improvement
• Scientific research and publication
• Electronic health record documentation

Terms and Conditions

1. I understand that I have the right to revoke this authorization at any time by submitting a written request.
2. I understand that revoking this authorization will not affect any actions taken before receiving my revocation.
3. I understand that these images may be shared with other healthcare providers involved in my care.
4. I understand that if images are used for educational or research purposes, my personal identifying information will be removed or obscured.

Duration

This authorization will remain valid for:

• Duration of treatment
• Specified time period: ________________
• Indefinitely

Signatures

Patient/Legal Guardian Signature: _________________ Date: _________

Witness Signature: ______________________________ Date: _________

Healthcare Provider Signature: ____________________ Date: _________

This authorization form complies with HIPAA regulations and state privacy laws.