Employee Requisition Form - The University Of Texas Health printable pdf download

The University of Texas Health Science Center at San Antonio

Consent for Photography

Patient Name:

DOB:

MRN#:

Parent or Legal Guardian:

I consent to have my (or child or an individual to whom I provide guardianship) image to be taken by the staff at

as described below.

I understand that my (or child or an individual to whom I provide guardianship) photographs, videotapes, digital, and

other images may be recorded to document and assist with my care and the payment of my (or child or an individual to

whom I provide guardianship). These images may be used to assist in the education of students and residents within the

institution. I understand that The University of Texas Health Science Center at San Antonio will own these images, but

that I will be allowed access to view them or to obtain copies of them at a reasonable cost. Other than for treatment,

education, and payment purposes, images that identify me (or child or an individual to whom I provide guardianship) will

be released and/or used outside the organization only upon written authorization from me or the patient representative.

Purpose of the disclosure for any purpose other than treatment, education, or payment purposes:

Dates of Treatment:

From: _______________________________ To: _______________________________

I may revoke or withdraw this consent at any time. Unless revoked earlier, this consent expires in one year unless I

specify another time period: _____________________________________. Withdrawal of consent must be made in

writing. Withdrawal of consent does not affect any information disclosed prior to the written notice of withdrawal.

My treatment will not be based on the completion of this authorization form. The information to be released by this

authorization may be re-released by the person or organization that receives it and may no longer be protected by Federal

or Texas privacy regulations.

I release and hold harmless The University of Texas Health Science Center at San Antonio, 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 photograph or other image.

By signing below, I am indicating that I have read and understand the “Consent for Photography” form. I am either the

patient or have the authority to give consent for the patient. My questions regarding this consent have been answered.

Patient or Patient Representative Signature)

Date

If Patient Representative, Relationship to Patient

Printed Name

06/2006

Employee Requisition Form - The University Of Texas Health