Photo Consent

Consent for the Use and Disclosure of Images, Voice and/or Written Testimonials

 
  • Information to Be Released – Covering the Periods of Health Care

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • *This Form to be used in conjunction with the Form entitled “entitled HIPAA AUTHORIZATION FOR USE/DISCLOSURE OF INFORMATION AND CONSENT/USE OF PHOTOGRAPHS AND AUDIO/VIDEO IMAGES”
  • Date Format: MM slash DD slash YYYY