Authorization To Use Image Personal Information printable pdf download

Authorization to Use Image/Personal Information

in Public Communications

I agree to allow UW Health to use information about me, including my name, my voice and/or photos or videos

of me in public communications such as printed materials, electronic communications, use on UW Health web

sites, in UW Health advertising and in social media.

I will let UW Health identify me to external parties for use in printed, broadcast or web news stories. I agree to

participate in photographs, videos and interviews with reporters from external news media. I understand that such

videos, photos and interviews may be rebroadcast or reprinted by other media outlets as well.

If a UW Health patient, I agree to be identified as a patient.

Special instructions/restrictions: _____________________________________________________________________________

This agreement will remain in effect unless you revoke your authorization.

I am: ❍ A Patient ❍ Other _____________________________________

______________________________________________________________________________________________________________________________________

Name – Last, First, MI

______________________________________________________________________________________________________________________________________

Street Address

______________________________________________________________________________________________________________________________________

City

State

Zip Code

______________________________________________________________________________________________________________________________________

Birthdate

Phone Number

Email Address

Signature (Individual or Parent/Guardian*)______________________________________________Date __________________

________________________________

If this form has been signed by the patient’s legal representative, please indicate your relationship to the patient:

* Generally, if you are 18 years of age or older, you are the only person permitted to sign this form to allow the use of your image or discuss of information about

you. If you are under the age of 18, your parent or guardian must sign this form for you. However, there are many situations in which this general rule does not

apply. For more information regarding who is authorized to sign this form, contact UW Health Marketing and Communcations at: (608) 262-6343.

ADDITIONAL INFORMATION REGARDING USE AND DISCLOSURE OF PATIENT INFORMATION

You should be aware of the following guidelines in signing this agreement:

federal health privacy laws, information they receive, may lose its protection

under federal health privacy laws, and those people may be permitted to re-

No Obligation to Sign. You do not have to sign this form, and you may refuse

release your medical information without your prior permission.

to do so. Unless permitted by applicable law, UW Health Care Providers may

Right to inspect. You have the right to inspect or copy information for which

not refuse to provide you treatment or other health care services if you refuse

to sign this form.

you are authorizing use or disclosure, with certain exceptions provided under

state and federal law. If you would like to inspect the information to

Revocation. You have the right to take away this authorization. Your written

be disclosed, contact the UW Health Marketing and Communications office at

revocation will be effective except to the extent that the person(s) and/

(608) 262-6343.

or organization(s) listed on this form have taken action in reliance on this

authorization. Your revocation must be made in writing and addressed to

For more information. Visit:

UW Health Marketing and Communications, 301 S. Westfield Road, Suite 250,

UW Health includes University of Wisconsin Medical Foundation, Inc.,

Madison, WI 53717 or e-mailed to .

University of Wisconsin Hospitals and Clinics Authority, and UW School of

Re-release. If the person(s) and/or organization(s) you are allowing to use your

Medicine and Public Health and other affiliated entities.

image/personal information are not health care providers or people subject to

FOR OFFICE USE ONLY

Project Description _____________________________________________________________________

PATIENTS ARE ENTITLED

TO A COPY OF THIS FORM

Physical Identification ___________________________________________________________________

AFTER SIGNING

Job Number _____________________ Department _______________________ Staff Initials _________

Event _______________ Event Date ___________ Event Location _______________________________

Tag(s) _______________________________________________________________________________

(5/2016)

PA-45581-16

Authorization To Use Image Personal Information

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