Release Authorizing Use of Personal Likeness
I,
consent to the use of my personal image and likeness, including but not limited to images representing and depicting the treatment provided to me and the effect thereof, by Reidsville Orthodontics for any lawful use Reidsville Orthodontics deems appropriate, including for treatment, advertising its services to the general public, via social media and electronic media such as Facebook and Instagram, for tagging, and for illustration/publication to the public at large.
I hereby relinquish any and all rights to my likeness or any image of me obtained by any photographic or digital means by Reidsville Orthodontics during the course of my treatment. I understand that I am entitled to no consideration, remuneration or payment for the use of my image in any advertising, promotional or educational materials.
I understand any image or likeness of me may be altered prior to use if deemed appropriate by Reidsville Orthodontics. I understand and agree that I have no right to be consulted about or approve of any such alterations before my image is used.
I understand that Reidsville Orthodontics will make all reasonable efforts to safeguard my privacy as required by applicable law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand, however, that Reidsville Orthodontics cannot guarantee my complete privacy in the event my image or likeness is used by third parties.
I understand that Reidsville Orthodontics may not and has not conditioned the rendition of treatment to me upon my authorization of the use of my image and/or likeness.
I have read the foregoing in its entirety and understand its terms.
Patient name
Patient/guardian signature
If patient is a minor, guardian relationship to patient
Notice of Privacy Practices Acknowledgement
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
● Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
● Obtain payment from third-party payers
● Conduct normal healthcare operations such as quality assessments and physician certifications
● Obtain patient or responsible party contact information from third-party payers, dental providers, and other healthcare providers
I acknowledge that I have received your
Notice of Privacy Practices
containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its
Notice of Privacy Practices
from time to time and that I may contact this 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 do agree then you are bound to abide by such restrictions.
List who we can give health information to below:
Patient name
Patient/guardian signature
If patient is a minor, guardian relationship to patient