Photo/Video Release Authorization Form for Geriatric Care

I, _______________________ (print name), hereby grant permission to _______________________ (practice/facility name) and its representatives to photograph and/or video record me and to use such media for the following purposes:

Authorized Uses (check all that apply)

• Medical documentation
• Educational purposes within the healthcare facility
• Professional medical education and training
• Marketing materials
• Social media content
• Other: _______________________

Terms and Conditions

1. I understand that these images/recordings may be used for legitimate medical, educational, or promotional purposes.
2. I acknowledge that I will not receive compensation for the use of these materials.
3. I understand that I may revoke this authorization at any time by submitting a written request.
4. This authorization remains valid until revoked in writing.

Privacy Considerations

• All media will be stored securely in accordance with HIPAA regulations
• Patient identifying information will be protected as required by law
• Media will only be shared with authorized personnel for approved purposes

Authorization

Patient/Legal Representative Signature: _______________________ Date: _______________________

If signed by Legal Representative: Print Name: _______________________ Relationship to Patient: _______________________

Witness

Witness Signature: _______________________ Date: _______________________

A copy of this signed authorization will be provided to the patient/legal representative upon request.