Patient Photography/Video Release

I authorize the Women's Health Specialists ("WHSFL") to take photographs and/or videos, or to allow third parties to take photographs and/or videos, or to use photographs and/or videos provided by the above named subject, for the following uses:

I understand that:

• I may revoke this Authorization at any time:
  • the revocation will not apply to information that has already been released in response to this Authorization.
• I may refuse to sign this Authorization:
  • WHSFL will not condition my treatment, any payment, enrollment in a health plan, or eligibility for benefits on receiving my signature on this Authorization.

I have been informed and understand that information disclosed pursuant to this Authorization may be subject to re-disclosure by a recipient of such information. It is possible that once disclosed, the privacy of the information may no longer be protected by federal and state privacy laws.