"*" indicates required fields
NOTE: This form is NOT required for photos or videos of patients used for the purposes of treatment or diagnosis, where the photo and/or video becomes part of the patient’s medical record and is not used for any other purpose.
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, including photographs of their babies delivered by WHSFL, for the following uses:
I understand that:
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.