Patient Photo and Video Authorization Form for Oncology

I, _______________________ (print patient name), hereby authorize _______________________ (practice/facility name) and its affiliated healthcare providers to take, record, and/or use photographs, digital images, and/or video footage of me for the following purposes:

Authorized Uses

• Medical documentation and electronic health record
• Treatment planning and monitoring
• Educational purposes within the medical community
• Research publications and presentations
• Marketing materials and patient education

Terms and Conditions

1. Duration: This authorization remains valid until revoked in writing.

2. Ownership: All photographs, images, and videos taken will remain the property of the practice/facility.

3. Privacy Protection:

   • No identifying information will be disclosed without explicit consent
   • Materials will be stored securely in compliance with HIPAA regulations
   • Access will be restricted to authorized personnel only

4. Revocation Rights: I understand that I may revoke this authorization at any time by submitting a written request.

Authorization

Patient Signature: _______________________ Date: _______________________

Witness Signature: _______________________ Date: _______________________

For Staff Use Only

Image/Video Reference #: _______________________ Date Recorded: _______________________ Staff Member: _______________________

This document is to be retained in the patient's medical record.