HIPAA Media Release Consent Form
Please complete this form to authorize the use and release of media content related to you or the person identified below.
Full Name of Person Giving Consent
*
First Name
Last Name
Relationship to Subject (if not self)
*
Please Select
Self
Parent/Guardian
Legal Representative
Other Relative
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Subject's Full Name (if different from above)
First Name
Last Name
Type of Media Authorized for Release
*
Photographs
Video Recordings
Audio Recordings
Written Testimonials
Purpose of Media Use
*
Educational Materials
Promotional Content
Website/Social Media
Other
Duration of Consent
*
Please Select
One-time use
One year from today
Until revoked in writing
Acknowledgment and Consent Statement
*
Signature of Person Giving Consent
*
Date of Signature
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: