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15) Beauty 05 Photo Authorization

Beauty Photo Authorization

I have consented to the taking of photography, audio/visual recordings, or other images of me by Home Towne Beauty, which will become part of my medical record. I understand that my photographs, videotapes, digital, and other images may be recorded to document and assist with my care. I acknowledge that the Practice will own these images, but that I will be allowed access to view them or to obtain copies of them as part of my medical record. I also understand that the images that identify me can be released and/or used outside the Practice only upon written authorization from me.

? This authorization is voluntary. My treatment will not be impacted, no matter if I sign this authorization or not.

? This authorization will end only when the use and disclosure of my information is no longer needed for the purposes agreed to above. I may revoke this authorization by mailing or faxing my written request to Home Towne Beauty.

? This withdrawal would affect only future use and disclosure of my information, photographs, and images, which have not been previously published or disclosed. I understand that this withdrawal would NOT affect any non-Home Towne Beauty TV, radio, newspaper, and other commercial media once they have received my information or recorded my image.

? Once my health information is disclosed as requested, it may no longer be protected by federal and state privacy laws and could be re-disclosed by the person(s) receiving it.

By entering your name above in text, you are acknowledging this as your electronic signature.
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