Patient Authorization for Photographs, Share Your Birth Care Story and Real Moms Blog
Please Print Clearly
Mother’s First Name: / Last Name:Address: / Apt / Unit:
City: / State: / Zip Code:
Email: / Phone:
Baby’s Name: / Birthday: / Weight: / Length:
I hereby authorize the use and/or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
I hereby authorize (check all that apply): representatives of St. Luke’s Hospital Moms365 Photography
To do the following (check all that apply):
Take photographs of me and/or my baby, to be used for: Happy Birthday Billboard (3-4 day display duration)
Share my birth care story (including photo), if I choose to submit one online.
Real Moms of Eastern Iowa Blog – to publish my blog articles if I choose to apply and am accepted as a blogger.
Photographs and recordings may be used for single or multiple purposes in any print publication or electronic media (including but not limited to newspapers, television broadcasts, radio broadcasts, magazines, brochures and web sites) as approved by UnityPoint Health System and/or the outside news organization specified above. This includes both publications and electronic materials prepared by UnityPoint Health System as well as outside news organizations.I realize I will receive no payment in connection with any publication or use of these photographs, video or audio recordings or statements, and I waive any claims that I or others have for such payments.
I do now and shall in the future hold UnityPoint Health System, its successors and assignees, as well as the physician(s) involved with my care, blameless and free from any claims in connection with the consent and use of the materials specified above.
This form has been explained to me—or I have read and fully understand this form—and all questions that I have been asked have been answered to my satisfaction.
This authorization may be rescinded within 24 hours before the recording/film is used unless stated otherwise.
- I understand that my health care and the payment for my health care will not be affected if I do not sign this form.
- I understand I may revoke this authorization at any time by notifying the Privacy Officer of UnityPoint Health System, but that if I do so, it will not have an effect on any actions taken before the revocation is received.
If representative, relationship to patient:
Signature:
Witnessed by:
Date / Time:
/ / Mom365 Photography Consents
(Please Initial)
_____ I authorize Mom365 Photography to photograph my newborn. I will be responsible for my baby’s safety and will stay by my baby at all times and assist if needed in moving my baby around for posing. All images belong to Mom365 and are copyrighted by law. It is illegal to use or reproduce portraits without mom365’s permission and digital cameras cannot be used during the photography session.
_____ Please use my newborn for advertising and display purposes. I know that they will never be used or associated with any names and release any liability from Mom365 or the Hospital.
Hospital Code:
Room:
Photographer:
Proofer:
Total:
Payment Method: