Patient Photo and Video Release Authorization Form

I, _____________________________ (print name), hereby authorize Dr. _____________________________ and [Practice Name] to take, store, and use photographs, digital images, video recordings, and/or audio recordings (collectively "media") of me for the following purposes:

Authorized Uses

• Medical documentation and electronic health records
• Treatment planning and monitoring
• Professional medical education and training
• Scientific publication in medical journals
• Patient education materials

Terms and Conditions

1. I understand that these media may reveal my identity and may contain sensitive health information.
2. I understand that I have the right to revoke this authorization at any time by submitting a written request.
3. I understand that revoking this authorization will not affect any actions taken before receiving my revocation.
4. I understand that I am not required to sign this authorization to receive medical treatment.

Media Usage Specifications (check all that apply)

□ Internal use only (medical records and treatment planning) □ Educational use within the practice □ Professional medical conferences and presentations □ Medical publications and journals □ Marketing materials (website, brochures, social media)

Authorization Period

□ One-time use only □ Duration of treatment □ Indefinitely □ Other: _______________

Signatures

Patient Signature: ___________________________ Date: ____________

Witness Signature: __________________________ Date: ____________

Provider Signature: _________________________ Date: ____________

This authorization is governed by HIPAA regulations and state privacy laws.