Occupational Therapy Media Release Authorization Form

[Practice Name/Logo]

Date: _____________

Patient Information

Patient Name: ________________________________ Date of Birth: ________________________________

Authorization for Media Release

I, _________________________, hereby authorize [Practice Name] and its occupational therapy staff to:

• Photograph
• Videotape
• Audio record
• Document digitally

my participation in occupational therapy evaluation, treatment, and/or consultation sessions.

Purpose and Use

I understand these media materials may be used for:

• Clinical documentation and treatment planning
• Educational purposes for healthcare professionals
• Quality improvement initiatives
• Marketing materials (if specifically authorized below)
• Insurance documentation requirements

Specific Authorizations

Please initial next to approved uses:

_____ Internal clinical documentation only _____ Professional education and training _____ Marketing materials (website, brochures, social media) _____ Insurance submission documentation _____ Research purposes (separate research consent required)

Terms and Conditions

1. I understand I may revoke this authorization at any time in writing
2. I understand I will not receive compensation for use of these materials
3. This authorization expires on: _____________ (or [ ] No expiration)
4. I understand I have the right to request copies of recorded materials

Signatures

Patient/Guardian Signature: _________________________ Date: _________

Witness Signature: _________________________________ Date: _________

OT Provider Signature: _____________________________ Date: _________

Revocation

To revoke this authorization, please contact: [Practice Contact Information]

Form ID: OT-MR-[YYYY] Version: 1.0