Patient Authorization for Medical/Media Filming, Advertising and Photography
I voluntarily consent and give authorization to appear in live broadcasts, films, photographs, videotapes, and audiotapes and to permit the use of such to be published or broadcast, republished or rebroadcast, including dissemination on the Internet.
I understand that the purpose(s) for which the information will be used include: Mount Sinai Medical Center staff education, educational or training needs of the medical profession, marketing and/or publicity activities carried out by or on behalf of Mount Sinai Medical Center, and/or any and all other purposes consistent with Mount Sinai’s mission of patient care, education and research.
I further authorize the modification or retouching of such films, photographs and/or tapes, and I waive any right to inspect or approve the finished product and/or any copy that may be used in connection with the above.
I understand and consent to the observation of my procedure by other health care providers for educational purposes and to my physician (or designee) making photographic, videotape, DVD or other similar photographic format of the procedure which shall remain in the physician’s custody and will not be made a part of my permanent record.
I further understand that my participation will not entitle me to remuneration or compensation now or in the future, and this shall be binding upon my heirs, personal representatives and assignees. As such, I assume full responsibility and hereby agree to hold Mount Sinai Medical Center harmless from any and all liability arising in connection with the above.
I understand I have the right to request cessation of recording or filming and if consent is withdrawn Mount Sinai will cease and desist distribution and/or use of file, videotape or photographs.
I understand that the information to be disclosed hereunder is subject to re-disclosure and that any such re-disclosure may not be subject to federal privacy restrictions. I understand that this authorization will not expire unless revoked by me and that I may revoke this authorization at any time before Mount Sinai Medical Center takes action in reliance on this authorization by notifying the Mount Sinai Medical Center Office of Public Relations, in writing, at 4300 Alton Road, Miami Beach, Florida 33140.
