Children’s Minnesota HIPAA consent for media, interviewing, photography and recording

Purpose of this form: To receive your authorization to release and use identifiable information about you, your specific condition, and the treatment you received. Together, these are referred to as your "Protected Health Information" or PHI, the sharing of which is otherwise prohibited under the Health Insurance Portability and Accountability Act (HIPAA).

I am filling this form out (check one) *

Section 1

* Indicates a required field

Guardian Information

* Guardians have legal authority to make medical decisions on behalf of the minor.

Child (Dependent) Information

Personal Information

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Additional included names (Please include any dependents or family members who should be covered by this release. For example, a child or sibling who is also in the photograph/video).

Section 2

I allow the following organizations to interview, record video or audio, and take photos of me/my child:

  • Children’s Minnesota
  • Media outlets
  • Partner organizations

The above organizations may share or use my/my child’s PHI, video and audio recordings, and photos in any of the following:

Newspapers; TV news broadcasts; radio; magazines; newsletters; press releases; professional/medical journals; trade or academic publications; video and audio recordings; podcasts; presentations; websites; social media (including the accounts of physicians and other providers of the above health care entities) and other digital media; blogs; documentaries; case or academic studies; professional and staff communications, education, training, research, marketing, fundraising, and promotional materials.

The above organizations may use or share my/my child’s information as authorized above for any of the following purposes:

Marketing, communications, media and public relations, promotions, events, training, education, fundraising, and research.

I understand that:

  • I can refuse to sign this form. If I don't sign it, this will not affect my care, my payment for care, or my relationship with any of the groups listed above.
  • My recorded information may be used in many ways. I may not be told when it is used.
  • Any photos, audio recordings, or videos taken in relation to this project are the property of Children’s Minnesota or of the media outlets that film or take pictures of me.
  • I will not be compensated (paid) for any use of my image or story.
  • This form will not expire.
  • If I change my mind after I sign this consent, I can take back this consent. If I do this, it will not apply to any information already released and used in any media materials. Children’s Minnesota and its partners cannot prevent someone else from seeing and using my PHI after it is released.
  • I can ask to take back my consent by writing to the Children’s Minnesota Marketing and Communications employee who worked on the story or mailto:[email protected].

You agree to provide special consent for release & use of certain sensitive PHI (select as appropriate):

Signature

Typing your name here means that you have read this information and understand it.

For staff only

Add a general description of the individual(s), situation, location for identification purposes.