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Model Release and HIPAA Patient Authorization Forms

Video and Student-Athletes

NCAA guidelines restrict how images of student-athletes can be used. Contact the Scarlet Knights’ communications department at 732-445-4200, for information regarding NCAA guidelines and the use of video involving student-athletes.

Model release forms must be obtained from people you are photographing or videotaping. These forms are required to use their image in any medium for educational, promotional, advertising, or other purposes. For public events, releases are not required; but it is strongly encouraged that model releases are signed by all subjects. One form is specifically for minors and must be completed by a parent or guardian.

As a health care provider, Rutgers must protect the privacy of our patients. When capturing images or obtaining other personal information from patients, we are required under the Health Insurance Portability and Accountability Act (HIPAA) to obtain their permission to use the information or images by completing the HIPAA Patient Authorization form (see below).

Model Releases

Department/division, building and room, school, address, and phone numbers can be modified to reflect your office. Other content should not be modified in any way without the assistance of the university counsel.

Download the Releases:

English Español

Model Release Form (DOC)

Permiso Uso Imagen (DOC)

Model Release Form for Minors (DOC)

Permiso Uso Imagen Para Menores de Edad (DOC)

 

HIPAA Patient Authorization Form

HIPAA authorization to release health information forms must be obtained from patients and/or patient legal representatives who disclose health information to you in any form (e.g., written, electronic, photographs, videos, reports, x-rays, lab results, and verbal) that you will use in communication materials (e.g., news releases, magazine stories, website content, brochures, advertisements, photos, videos, etc.).

On the HIPAA authorization form, department/division, building and room, school, address, and phone numbers can be modified to reflect your office. Other content should not be modified in any way without the assistance of the university counsel.

You should

  • complete the masthead information for your unit, and fill in the address where revoked authorizations must be mailed or delivered;
  • before interviewing, photographing, or videotaping begins, give the form to the patient and/or patient legal representatives and explain its purpose;
  • have the person sign the form, date it, and provide the contact information requested;
  • sign the form as the witness;
  • if you complete page two, have the patient/patient legal representative initial page two;
  • provide a copy of the authorization to the person, and keep the authorization on file.

Download the Form:

HIPAA Patient Authorization Release Form (DOC)

For additional information or questions, contact:

Jeanne Weber, Director
Office of Creative Services
Department of University Communications and Marketing
848-445-1934
Email
Location: Davidson Hall, Busch Campus