HIPAA AUTHORIZATION FOR USE/DISCLOSURE OF INFORMATION AND CONSENT/USE OF PHOTOGRAPHS, AUDIO AND VIDEO IMAGES
The Center for Pediatric Dental Care, LLC respects the privacy of our patients, visitors, and staff. Ensuring that medical information is kept confidential is among our highest priorities. The Center for Pediatric Dental Care, LLC seeks your permission to use your medical information and your consent to allow us to take and use audio/video/photographic material of you in The Center for Pediatric Dental Care, LLC's internal and external communications, including medical and general interest publications and medical and patient education information, marketing, and distribute such materials online, in print, and in news media (such as TV, radio, newspapers, and magazines). To ensure that The Center for Pediatric Dental Care, LLC is acting in accordance with your wishes, and using your personal information with your authorization, we ask you to fill out and sign this form. The Center for Pediatric Dental Care, LLC will keep a copy of your written permission on file.
I am not required to sign this authorization. The Center for Pediatric Dental Care, LLC does not conditiontreatment, payment, benefit eligibility, or enrollment activities on the signing of this form. I can request a copy of this authorization be mailed to me. I understand that I will not be entitled to any payment or other form of remuneration as a result of any use of any information and audio/video/photographic material.
I am aware that my protected health information will exist forever in either a recorded, printed, and /or electronic version or other version as may develop over time and that once it is published or disclosed in any form it will continue to be used. I understand that information about me or my child used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and will no longer be protected by the federal regulations protecting privacy of an individual's health information under the Health Insurance Portability and Accountability Act of 1996 and other applicable federal and state law.
I understand that I may revoke or withdraw this permission at any time to prohibit future use of my information. To do so, I must send written notice to The Center for Pediatric Dental Care, LLC Privacy Officer at 209 Harvard St., Second Floor, Brookline MA, 02446. I understand that The Center for Pediatric Dental Care, LLC, as well as other persons or entities, will retain copies of any such electronic or printed versions and shall retain these versions forever and that any revocation of this authorization will only extend to the versions of the information within The Center for Pediatric Dental Care LLC's control that have not been previously published. If not revoked/withdrawn by me, this authorization expires ten (10) years from the date that I sign it.
I do give my permission for The Center for Pediatric Dental Care, LLC to use the above patient's name and share details of my or his/her treatment and experience as a patient in communications produced by or on behalf of The Center for Pediatric Dental Care, LLC and consent to take and make use of my and/or the abovementioned name/ video/photographic images in publications produced by or on behalf of The Center for Pediatric Dental Care, LLC. This permission extends both to electronic versions on The Center for Pediatric Dental Care, LLC websites and other internet/electronic applications as well as to printed, filmed, and taped versions.