I have consented to the taking of photography, audio/visual recordings or other images of me by New Skin and Body Aesthetics staff/representatives ("Practice"), which will be become part of my medical record. I understand that my photographs, videotapes, digital, and other images may be recorded to document and assist with my care and the payment of my bill. I acknowledge that the Practice will own these images, but that I will be allowed access to view them or to obtain copies of them as part of my medical record.
I also understand that the images that identify me can be released and/or used outside the Practice only upon written authorization from me. Therefore, I authorize Practice to use my photographs, videotapes, digital, and other images for educational, commercial and other purposes as follows (please check any items you do not wish to authorize):
1.Practice internet website 2.Practice posters, publications, photograph books (by, on behalf of, or about Practice) 3.Media, Internet websites, publications (TV, newspaper, magazine, any other media/social media/website outside the Practice) 4.Healthcare related presentations, publications, seminars, conferences and meetings (within or outside the Practice) 5.Other (if applicable)
Iauthorize the disclosure of the following protected health information to be used in conjunction with the photographs, videotapes, also digital, and other images will include (if applicable):
Inaddition, I understand that the photographs, videotapes, digital, and other images may incidentally disclose additional protected health information related to my treatment, condition, procedure, surgery or other protected health information associated with the photographs, videotapes, digital, and other images, and I authorize this disclosure.
This authorization will expire in 80 years from the date this consent was signed, unless otherwise noted here: The Practice IS NOT receiving director indirect remuneration from a third party in connection with the use/disclosure of the protected health information described in this authorization. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the Practice's Privacy Officer. I understand that a revocation is not effective to the extent that the Practice has relied on the use or disclosure of theprotected health information. I understand that, except as otherwise provided in this authorization, the Practice may use or disclose my protected health information in accordance with Practice's Notice of Privacy Practices.
Iunderstand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act or other applicable laws or regulations. I release and hold harmlessthe Practice, its staff and employees from any and all claims or causes of action that I may have of any nature whatsoever, which may in any manner result from the use of the photographs or other images.
I understand that the Practice will not condition my treatment, payment or eligibility for benefits on whether I provide authorization for the requested use.
I certify that I have read this release carefully and fully understand its terms. If I have any questions I can contact New Skin and Body Aesthetics at (949)485-2100.