We are pleased when patients are willing to communicate their experience and information regarding the treatment received at Water’s Edge Dermatology. We respect the privacy of our patients and seek your permission to use your medical information and your consent to allow us to take and use audio/video/photographic material of you in internal and external communications and distribute such materials online, including WED website and social media, and in print. To ensure that we adhere to your wishes for how your protected health information (PHI) may be shared, please complete the following:
I give permission for Water’s Edge Dermatology to use my name and share details of my treatment and experiences as a patient in any communications (print or online) produced by or on behalf of Water’s Edge Dermatology to include audio, video and photographic images.
If I decide to sign this form, I understand that I have the right to require that audio, videoing and/or photography may be stopped at any time.
I understand that I may revoke this Authorization in writing at any time, except to the extent that action has already been taken in response to the Authorization. I understand that the information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected under federal privacy law. I understand that I may refuse to sign this Authorization. If I do not sign this Authorization, Water’s Edge Dermatology will continue to provide treatment and seek payment for services provided.