Photo Disclosure and Authorization

 

Authorization for Use or Disclosure of Patient Photographic and or Video Images

 

Authorization:

I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by Knutson Family Dentistry. I understand that information disclosed pursuant to this authorization may be subject to redisclosure to this authorization may no longer be protected by HIPAA privacy regulations.

 

Purpose:

The photographic/video images, and/or testimonial will be used for: Social Media and/or Advertising

Revocability:

I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail.

No Treatment Conditions:

I understand that the practice cannot condition treatment on whether or not I sign this authorization.