Photography and Video Recording Authorization Form for Psychiatric Practice

I, _________________________________ (print name), hereby authorize [Practice Name] and its designated representatives to photograph, videotape, and/or record me for the following purposes:

Authorized Uses (check all that apply):

• Clinical documentation
• Treatment planning and monitoring
• Educational purposes (teaching/training)
• Research purposes
• Marketing materials
• Other: _________________________________

Terms and Conditions

1. I understand that these images/recordings will become part of my medical record and will be treated with the same confidentiality as other medical record information.

2. I acknowledge that:

   • No compensation will be provided for the use of these images/recordings
   • I may revoke this authorization at any time in writing
   • Revocation will not affect any actions taken prior to receiving the revocation

3. For educational/research/marketing uses:

   • My identity may be concealed or revealed as specified: ________________
   • Materials may be used in: [ ] Internal use only [ ] Public domain

Duration

This authorization expires:

• On date: //_____
• Upon completion of treatment
• Other: _________________________________

Signatures

Patient/Legal Guardian: _________________________ Date: //___

Witness: _____________________________________ Date: //___

Clinician: ____________________________________ Date: //___

Revocation

I hereby revoke this authorization (signature): _________________ Date: //___