Patient Photo and Video Release Authorization Form

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record Number: ___________

Authorization

I, ______________________, hereby authorize [Practice Name] and its affiliated endocrinologists to:

• Take photographs, video recordings, and/or digital images
• Store these media in my medical record
• Use these media for the following purposes (check all that apply):

□ Medical documentation and treatment planning □ Educational purposes within the medical community □ Research publications (de-identified) □ Patient education materials

Specific Conditions/Procedures

This authorization applies to images/recordings of:

• □ Thyroid examination findings
• □ Visible endocrine condition manifestations
• □ Procedure documentation
• □ Other: ____________________

Understanding and Rights

I understand that:

1. I may revoke this authorization at any time in writing
2. Future use of existing media cannot be retracted
3. My treatment is not conditional upon signing this release
4. My information will be protected according to HIPAA guidelines

Signatures

Patient/Guardian Signature: _________________ Date: _________

Witness Signature: ________________________ Date: _________

Physician Signature: _______________________ Date: _________

Expiration

This authorization expires on: _____________ (or □ No expiration)

Form version: [Date]