______________________________ MEDICINE

AUTHORIZATION FOR USE OF INFORMATION AND PHOTOGRAPHS

______________________________ Medicine is grateful to patients who are willing to share their stories. Information about treatment you received here, the people you met and your experiences can prove enormously helpful to others interested in knowing more about health care today.

At the same time, the privacy of patients and visitors, as well as the confidentiality of medical and related information, are among our highest priorities. Therefore, permission always is sought from patients or their families or guardians to provide names, photos and information about hospitalization and treatment to the news media. A permission is also sought to use this information and visual material in official Hopkins communications, such as publications, articles, brochures, Web sites, video and audio tapes.

To make certain that we are using your personal information with your authorization, Hopkins keeps on file a copy of your written permission. Would you, therefore, please take a minute to fill out and sign this form?

 

• I do ___, I do not ___ give my permission for ______________________________ to share information about my treatment and experiences as a Hopkins patient in publications produced by ______________________________. This permission extends both to electronic versions on the ______________________________ Web sites and printed versions.

• I do ___, I do not ___ give my permission for ______________________________ to use my photographs or images in publications produced by ______________________________. This permission extends to both electronic versions on the ______________________________ Web sites and printed versions.

• I do ___, I do not ___ give permission for ______________________________ to provide my name and contact information to the public news media including, but not limited to, TV, radio and newspapers in connection with my treatment and experience as a Hopkins patient.

• I do ___, I do not ___ give permission for ______________________________ to disclose my photographs or other images, or information about my treatment and experiences as a Hopkins patient to the public news media including, but not limited to, TV, radio and newspapers, and other commercial media photographers and videographers.

• I do ___, I do not ___ give permission for Hopkins to allow TV, radio, newspapers and other commercial media photographers and videographers to make images of me/my child(ren)/my family member for purposes of illustrating my treatment and experience as a Hopkins patient.

________________________________________________________________________________

 

This authorization is valid for one year from date signed. This means that ______________________________ or public news media has one year to print my story, photographs or other images, or to share my name and contact information with the public news media.

I understand that ______________________________ has patient confidentiality policies and procedures in place to protect my health information. I understand that ______________________________ will do everything reasonably possible to protect my health information and abide by this authorization. These procedures make it highly unlikely that my health information will be improperly redisclosed. However, if my health information is disclosed to third parties, I understand that Hopkins cannot guarantee that my health information will be 100% protected against improper disclosure. In the unlikely event that there is improper disclosure, my health information may no longer be covered by these privacy protections.

 

I am not required to sign this authorization. ______________________________ does not condition treatment, payment, benefit eligibility or enrollment activities on the signing of this form. I will receive a copy of this authorization upon signature.

I understand that I may withdraw this permission at any time for future use or disclosure of my information by following the guidelines on the back of this form. However, I understand that this withdrawal would only affect future use and disclosure of my information, photographs and images, which have not been previously published.

Patient Name: __________________________________________________________________
 
(first)
(m. initial)
(last)
       
Signature: _______________________________ Date: _______________________________
   
Address:
__________________________________________________________________
 
(street address)
  __________________________________________________________________
 
(city)
(state)
(zip code)
       
Phone: _______________________________    
 
(area code) (home phone number)
    

 

For personal representatives, please provide the following and attach contact information.

I _________________________________ represent that I am the healthcare agent/guardian/surrogate/parent
 
(insert your name)
(circle one of the above)
of the patient named above.
     
Personal Representative Signature: _________________________________
     
Address: _________________________________
   
Phone: _________________________________
   
If you are the healthcare agent or guardian, please provide proof of your authority to act on behalf of the patient.