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Photography/HIPAA Consent

Photography Consent

I hereby voluntarily grant permission to The OCRC to take and use photos of myself (patient) for purposes of treatment and monitoring progress. The OCRC will NOT post your pictures online or use them for purposes other than listed above. I further understand that no form of compensation shall become payable to me for the use of these photographs. I hereby release The OCRC and its agents from any and all claims and demands arising out of or in conjunction with the use of these photographs.

Patient/ responsible party


understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. A copy of our ?Notice of Privacy Practices? is made available at the receptionist desk. I understand that this information can and will be used to: 1. Conduct, plan and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly; 2. Obtain payment from third party providers; 3. Conduct normal healthcare operations such as quality assessments and physician certifications. I understand that Oregon Cosmetic and Reconstructive Clinic has the right to change its Notice of Privacy Practices from time to time and that I may contact the organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions but if you agree than you are bound to abide by such restrictions.

Patient/ responsible party
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