FEINER PLASTIC SURGERY
PATIENT PHOTOGRAPHIC AUTHORIZATION AND RELEASE
This authorization document has been prepared to request your permission to take photographs. We take your privacy very seriously and it is important to carefully review the document and make selection of the appropriate consent below.
By signing below, I
consent and acknowledge that photographs will be taken of me or parts of my body before and after each surgery by Dr. Feiner or his designee, in connection with the plastic surgical procedures involving the face, breasts, body, or extremities performed by Dr. Feiner.
I understand that in some circumstances the photographs may portray features that shall make my identity recognizable. I understand that I have the right to revoke this authorization in writing at any time, but if I do so it will have no effect on any actions taken prior to my revocation. I understand that the information disclosed, or some portion thereof, may be protected by law and/or the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
1. WEBSITE AND MEDIA
INITIALS
Photographs taken of me or parts of my body as well as details regarding medical services that I have received at Feiner Plastic Surgery may be used in any print or broadcast media, including, but not limited to newspapers, pamphlets, office photo albums, educational films, internet, and television in order to inform the public about surgical procedures and methods. Further, I release and discharge Feiner Plastic Surgery, and all parties acting under their license and authority from any and claims or actions that I may have relating to such use and publication, including any claim for payment in connection with distribution or publication of these materials in any medium. I give my consent as a voluntary contribution in the interest of public education and my consent is given on the condition that I am not identified by name at any time during any use or publication of these materials by any party.
2. PHOTO ALBUM AND MEDICAL CARE
INITIALS
Photographs taken of me or parts of my body as well as details regarding medical services that I have received at Feiner Plastic Surgery may be used in the photograph album in order to inform other plastic surgery patients about plastic surgery methods. Further, I release and discharge Feiner Plastic Surgery, and all parties acting under their license and authority from any and claims or actions that I may have relating to such use and publication, including any claim for payment in connection with distribution or publication of these materials in any medium. I give my consent as a voluntary contribution in the interest of public education and my consent is given on the condition that I am not identified by name at any time during any use or publication of these materials by any party.
3. MEDICAL CARE ONLY
INITIALS
Photographs taken of me or parts of my body can be used solely for the purpose of documentation of medical care with Feiner Plastic Surgery and to request authorization for surgical procedures with my insurance company. The photographs and all details regarding medical services rendered to me will be kept confidential within my personal medical file at Feiner Plastic Surgery. Certain procedures require supporting photographic documentation for insurance authorization.
I grant this consent and certify that I have read the above Authorization and Release and fully understand its terms. I understand that I may refuse to sign this authorization and such refusal will have no effect on the medical treatment I receive from Dr. Feiner.
Patient
Date
Witness
Date
(MINORS ONLY)
I have read the above Authorization and Release. I am the parent, guardian or conservator of , a minor. I am authorized to sign this consent on his/her behalf and I grant this consent as a voluntary contribution in the interest of public education.
Parent/Guardian
Date
