Consent to Photograph and/or Interview

Consent to Photograph and/or Interview - ENGLISH

Name

This field is for validation purposes and should be left unchanged.

I, , consent and authorize El Paso Children’s Hospital (EPCH) to take photographs and/or videos, televise and/or interview for the following uses:

On EPCH internet and intranet sites;
In EPCH publications and brochures;
In the public media, such as newspapers, magazines, internet, social media, and television;
In presentations, publications, brochures, advertisements, or articles by non-EPCH agencies or companies;
In professional journals and other publications, including textbooks and electronic publications;
In presentations by EPCH staff, employees, and contracted staff, including professional and educational conferences or seminars.

I also agree that EPCH may use, or permit others to use, the negatives, videos, or prints prepared for such purposes as deemed necessary by EPCH.

I further authorize the modification, editing, or retouching of any photographs and/or video, and the publication of information relating to .

I understand that I may refuse to sign this authorization, and that my refusal to sign will not affect my/the patient’s ability to obtain treatment. I understand that this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance of this authorization. I also understand that I have a right to request cessation of filming, photographing, or recording.

I understand that the information released may be subject to re-disclosure by some recipients and may no longer be protected by federal and state privacy rules related to health information.

Authorization for use in treatment or at patient or family’s request will not expire. Authorization for other uses and disclosures indicated above will expire one (1) year from the date of signature. I acknowledge, however, that EPCH is unable to control the continued use of photographs or videos by non-EPCH personnel after expiration of this authorization.

By signing below, I acknowledge and represent that I am at least eighteen (18) years of age (or a legally emancipated minor) and am fully competent, have carefully read this authorization and release, and sign it voluntarily as my own free act and deed.

I hereby give my consent as described above.

Signature (typed name): Relationship to Patient:

You must revoke this authorization in writing. To revoke this authorization, send a written request with a copy of this form to:
El Paso Children’s Hospital, 4845 Alameda, El Paso, Texas 79905, Attention: EPCH Marketing

Questions? Please contact 915-298-5444 and ask to speak with the EPCH Marketing Department.

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