AUTHORIZATION FOR PHOTOGRAPHIC/VIDEO RELEASE
COMHAR is committed to protecting the privacy of your health care treatment and information. Because of this commitment and various State and Federal regulations, we must obtain your written authorization before we may use or disclose information about you for the purposes described below. This form provides that authorization and helps us make sure that you are properly informed of how this information will be used or disclosed.
Please read the information below carefully before signing this form. This Authorization for Photographic/Video Release gives your consent for the public display, dissemination and/or distribution of your identity, the photograph, video, other electronic likeliness of you, or other personally identifying information, through any medium, that is, radio, television or print (such as a newspaper) or the internet (world wide web), for publicity, informational or other purposes as determined by COMHAR.
I, ______________________________________________, hereby understand, agree and authorize COMHAR, Inc. to take my photograph or video of me and use my name, identity or other identifiable information, or a photograph or video of me (collectively “personally identifiable information”) at its discretion, for release, display, publication, dissemination or distribution to the public, including print media, newspaper, radio, television, or to the internet (such as the COMHAR website, or any other COMHAR endorsed website) for the purpose of publicizing COMHAR and its services, marketing, public relations or other purpose at COMHAR’s discretion. I understand that release of my personally identifiable information will identify me to the general public as someone who receives services from COMHAR and/or identify the reasons for such services, especially if I allow COMHAR to disseminate or distribute an article written by me.
This authorization expires only upon my written revocation.
Date of Authorization:____________________________________ Expiration Date or Event: _____________________________
Statement of Authorization:
I hereby authorize the use and/or disclosure of my personally identifiable or protected health information as described above. I have been informed and understand the following:
1. I have a right to revoke this authorization at any time by notifying COMHAR in writing. If I do revoke this authorization it will only affect release of future information. It will not apply to information already displayed, published, disseminated, or distributed by COMHAR in reliance upon my prior authorization.
2. I understand that once my information has been released, COMHAR cannot guarantee that other individuals will not re-distribute it and it will no longer be protected.
3. I understand that my right to health care treatment will not be affected if I do not sign this authorization.
4. I have been informed of my right to examine/inspect any information. Any request to examine/inspect must be made at the time of signing this authorization, as COMHAR cannot guarantee the information will be available for review later.
5. I certify by my signature below that I understand the nature of this authorization and that all information contained herein has been explained to me and to my satisfaction.
Signature of Member and Date _______________________________________ COMHAR Witness: __________________________
Copy offered/given to Consumer or Member (HIPAA requires a copy be provided.)