Form Ds 6017 Media Access Request And Agreement - California Department Of Developmental Services Page 2
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2State of California—Health and Human Services Agency
Department of Developmental Services
Media Access Request and Agreement
DS 6017 (Rev 02/2016)
MEDIA ACCESS AGREEMENT
I understand that the Department will release consumer information only as allowed by the privacy rules of the Health
Insurance Portability and Accountability Act of 1996 (HIPAA), the California Confidentiality of Medical Information Act, the
California Welfare and Institutions Code and all other applicable state and federal laws.
As a condition of and in consideration for the Department’s grant of access to its facilities for
photographing, filming, recording, interviewing or other media related activities, if granted access, I
understand and agree to the following:
I understand and agree to comply with the privacy rules of the Health Insurance Portability and Accountability Act of
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1996 (HIPAA), the California Confidentiality of Medical Information Act, the California Welfare and Institutions Code and
all other applicable state and federal laws, to safeguard patient privacy.
I understand and agree not to access any Developmental Centers or State-Operated Community Facilities for
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photographing, filming, recording, or interviewing activities without obtaining prior authorization from the Department.
I understand and agree that media representatives shall contact the Developmental Center or State-Operated
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Community Facility spokesperson through the main office immediately upon arrival to the Developmental Center or the
State-Operated Community Facility. Media representatives shall be escorted by the Department’s Public Information
Officer or his/her designee at all times while on the premises.
I understand and agree that media representatives shall present valid identification and will wear media identification
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credentials at all times while on facility premises. In the case where the representative does not have media
identification credentials, I understand the representative shall wear the media badge/pass supplied by the facility.
I understand and agree that I shall not interview, audio record, photograph, videotape, film, or otherwise record the
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likeness of any individual, until or unless the individual or person authorized to consent has signed a written consent
form.
I understand and agree that each person portrayed in any visual image must consent to the disclosure prior to the
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release of the image. Only the image of the person(s) who have consented to the disclosure shall be released. Images
of non-consenting persons shall not be published or disseminated in any way.
I understand and agree that I will access, use, and disclose confidential information only as authorized by the
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Department and the consumer or individual authorized to consent. This means that I will only access, use, and disclose
confidential information that I have been given authorization to access, use, and disclose.
I understand and agree that Department authorization is for a single, specific use. Authorization for subsequent use
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shall be obtained from the Department AND from the individual(s) authorized to consent.
My signature below indicates that I have read, understand, and agree to abide by all of the requirements
described above.
Signature __________________________________________
Date _____________________________________
Printed Name ______________________________________
Organization _______________________________
Contact Phone No. _______________________ E-mail Address __________________________________________
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