HIPAA Consent for Media, Interviewing, Photography, and Recording

Purpose of this form is:

To receive your authorization to release and use identifiable information about you, your specific condition, and the treatment you received. Together, these are referred to as your "Protected Health Information" or PHI, the sharing of which is otherwise prohibited under the Health Insurance Portability and Accountability Act (HIPAA).

Survey Date

Patient Name

* must provide value

Patient Date of Birth

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M-D-Y

Additional Included Names

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Preferred phone

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Site(s) of treatment (hospital/clinic/other)

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I allow the following to interview, record video or audio, and take photos of me:

Fairview Health Services as well as identified affiliates including but not limited to Acadia Healthcare, Behavioral Healthcare Providers, Ebenezer, Fairview Pharmacy Services, Fairview Physician Associates, Fairview Range Medical Center, Grand Itasca Clinic & Hospital, M Health Fairview Clinics and Surgery Center - Minneapolis, M Health Fairview Masonic Children's Hospital, and M Health Fairview University of Minnesota Medical Center.
University of Minnesota Physicians
University of Minnesota including but not limited to the University of Minnesota Medical School and its departments, the Office of Academic Clinical Affairs, the University of Minnesota Foundation; academic centers and institutes such as Masonic Cancer Center or Masonic Institute for the Developing Brain; and Gopher Athletics.
Media outlets

The above organizations may share or use my PHI, video and audi recordings, and photos in any of the following:

Newspapers; TV news broadcasts; radio; magazines; newsletters; press releases; professional/medical journals; trade or academic publications; video and audio recordings; podcasts; presentations; websites; social media (including the accounts of physicians and other providers of the above healthcare entities) and other digital media; blogs; documentaries; case or academic studies; professional and staff communications, education, training, research, marketing, fundraising, and promotional materials.

The above organizations may use or share my information as authorized above for any of the following purposes:

Marketing, communications, media and public relations, promotions, events, training, education, fundraising, and research.

I understand that:

I can refuse to sign this form. If I don't sign it, this will not affect my care, my payment for care or my relationship with any of the groups listed above.
My recorded information may be used in many ways. I may not be told when it is used. I will not be asked to approve usage again.
Any photos, audio recordings, or videos taken in relation to this project are the property of Fairview, Univeresity of Minnesota Physicians, University of Minnesota, and their affiliates listed above, or of the media outlets that film or take pictures of me.
I will not be compensated (paid) for any use of my image or story.
This form will not expire.
If I change my mind after I sign this consent, I can take back this consent. If I do this, it will not apply to any information already released and used in any media materials. Fairview and its partners cannot prevent someone else from seeing and using my PHI after it is released. I can ask to take back this consent by writing to: Fairview Communications & Public Affairs, 1700 University Ave., M-1115 - 5th Floor, St Paul, MN 55104, Attn: Consent Form.

Limits:

* must provide value

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You agree to provide special consent for release & use of certain sensitive PHI (select as appropriate):

Drug/alcohol abuse, diagnosis & treatment

HIV/AIDS testing, diagnosis & treatment

Genetic testing

Mental health diagnosis & treatment

Sickle cell anemia diagnosis & treatment

Signature Date

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M-D-Y

Signature

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Add signature

I am:

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The subject of this form

An authorized signer for the subject of this form

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Authorized Signer Relationship

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Authorized Signer Name

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Completed form PDF

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