USF Patient Media Consent Form

USF Patient Media Consent Form

Patient Information Authorization for Release Through Stories, Video, Photography, Marketing and News Media
Date of Consent*

MonthDayYear
Date
Story Topic
Faculty/Students Featured in Story
Patient Name*

First NameLast Name
Patient Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City and State*
Patient Phone Number*
Please enter a valid phone number.
Patient Email Address*
example@example.com
Authorization Statement
I authorize USF Health and its affiliates and agents to take photographs, produce videos, audio recordings, electronic files, or other types of media products that capture my name, voice, image to be released to members of the media, USF Health and organizations acting in official capacity of USF Health. Additionally, I authorize USF Health to use my information for the purpose of:

- News media (online, print, broadcast)
- Publications and/or promotional materials
- Closed circuit television programs
- Advertisements
- USF Health websites and social media
- Medical and/or educational training

Information to be disclosed includes:

- Photographic images/illustrations
- Video and audio of me and/or my voice
- Images from records (scans and/or X-rays)
- Information about my medical condition and/or prognosis
- Information about date(s), time(s) and type(s) of treatment received
- Other (please specify in the box below)
If other is applicable above, please specify
Acknowledgment Statement
I acknowledge that once my information is disclosed, it will no longer be considered protected health information under HIPAA and may be redisclosed without my further consent for use by USF Health and approved uses by third parties. I further understand this authorization is voluntary, without compensation, and that I may refuse to sign this authorization. Refusal to sign will not affect my ability to obtain treatment or receive payment from my insurance company. Refusal will also not affect my eligibility for benefits. I understand that, by signing this form, I affirm that I have authority to sign this document, authorize the use of disclosure of protected health information, and declare there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.

This authorization will remain in effect indefinitely from the date below until such times as you notify USF Health of your intent to revoke this authorization. A written request to revoke this authorization can be sent to USF Health Communications and Marketing via email at healthcommunications@usf.edu. This revocation of this authorization will be effective the day the written request is received and acknowledged by the above mentioned. If I revoke the authorization, it will not have any effect on any actions taken by USF Health, or any third parties, prior to the processing of the revocation.
Are you the patient or a representative?*

PatientRepresentative (parent, guardian, or legal representative)
If not the patient, state your reason/relationship to the patient
If not the patient, please provide your full name

First NameLast Name
Signature of Patient or Representative (e-signature)*

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Date of Signature*

MonthDayYear
Date
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