Authorization and release for the use and disclosure of protected health information for marketing  and educational purposes

As you may or may not know, plastic surgeons frequently take photographs of their patients before, during, and after their operations.  These images are used as part of your medical record, to document your appearance before and after a procedure.  They are also sometimes used for credentialing purposes, education of other medical professionals or patients, and for advertising.  This form is used to document your understanding and consent for this. I hereby authorize the Plastic Surgery Center and their  physicians, associates or staff to take pre-operative, intra-operative, and post-operative photographic or video images of me. I additionally consent to photographs and/or videotapes of my interview.

PATIENT NAME_________________________________________________________________________________

SOCIAL SECURITY NUMBER ________________________________ DATE OF BIRTH ______________________

I hereby authorize Charleston Area Medical Center, Inc. ("CAMC") to use and disclose the protected health information described below for the purposes of marketing and education. The description and amount of protected health information to be used and disclosed as follows:  (please describe the information as specifically as possible, including dates where appropriate)____________________________________________________________________________________________________

____________________________________________________________________________________________________

I understand and agree that my protected health information, described above, may be published and republished, separately or in connection with other protected health information, in medical books, journals, presentations, or programs, or in any other manner that furthers the purposes of medical education and research.  I also consent to the publication, republication, use and disclosure of my protected health information in advertising, marketing, and informational materials prepared by or on behalf of CAMC.  As such, I understand that my protected health information, described above, will be seen by the general public.  I understand and agree that I will not be compensated for the use of my protected health information.

This authorization expires five years after the date below for any new uses or disclosure of my protected health information.  I understand and agree, however, that documents and other publications of my protected health information, regardless of the manner, media or format, which were made before the expiration of this authorization, may be used indefinitely into the future for the purposes stated herein.

I understand that once my protected health information is disclosed in educational and or marketing materials, the information described above may be redisclosed and is no longer protected by federal privacy regulations. I understand that CAMC cannot control, supervise, or be responsible for the use and disclose of my protected health information by third parties who may receive the educational and /or marketing materials.

I understand that I may inspect and receive a copy of this authorization. I understand that I will not be refused treatment simply because I do not sign this authorization.

I understand that I may revoke this authorization at any time in writing, except where action has already been taken in reliance upon this authorization. I understand and agree that once my protected health information has been published either in an educational or marketing vehicle of any kind or format, I cannot revoke my authorization for the use and disclosure of my protected health information in existing publications or in republications of those vehicles, and I can only prevent the use and disclosure of my protected health information in new and/or original publications. My revocation will not be effective until I submit a written request to revoke the authorization to the CAMC Privacy Office (for more information call the Privacy Office at 304-388-1187 or review CAMC's Notice of Privacy Practices).

A photocopy or facsimile copy of this Authorization is to be used and considered as having the same effect as the original of said Authorization.

_______________________________________________                _______________________________________

Signature of Patient or Representative                                             Date

_______________________________________________                _______________________________________

Name of Personal Representative (if applicable)                               Statement of Relationship to Patient