PIEDMONT ACCESS TO HEALTH SERVICES, INC.
Policy Number: 01-04-010
SUBJECT: Use of Patient Image for Marketing or Press Release
EFFECTIVE DATE: 09/23/2013
REVIEW/REVISE: 09/09/2014, 03/21/2016
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POLICY: It is PATHS’ policy that written consent shall be obtained before using a patient’s information and likeness or image if a patient’s identity can be determined. All communications pertaining to Marketing or a Press Release for publicity or interviews should be directed to and approved by the Chief Executive Officer or the Chief Operating Officer.
This policy does not apply to use of images for treatment or payment purposes as defined under HIPAA.
PROCEDURE:
1. Written Consent required - The patient, or the patient’s legal representative, will be asked to provide consent for PATHS to photograph, record video, and audio or create other images of the patient, via PATHS Media Talent Release Form that is signed by the patient. The consent should contain a description of the photography. This consent form limits the use of such media to purposes related to and approved on this form. Verbal consent is not an authorized form of approval and will not be obtained in place of the consent form.
2. Family/Personal Use - When a patient or the friends and family involved in a patient’s care request PATHS staff to make photographs solely for personal use (such as for family photo albums or a baby book), PATHS is not required to obtain written patient consent prior to taking the photograph.
3. Cessation of Filming or Photography – In order to provide for the safety and security of patients, employees and visitors, PATHS can request filming or photography for personal use be stopped.
4. Documentation – The photography/media should be date and time stamped when possible. Copies of the PATHS Media Talent Release Form shall be retained in the patient’s health record with other consent and authorization forms.
5. Sanctions - Violation of this Policy will result in disciplinary action, in accordance with PATHS Personnel Policies.
SIGNATURES:
______/ ___ /______
Chief Executive Officer Date
______/ ___ /______
Chief Operating Officer Date
MEDIA TALENT RELEASE FORM
Date of Photo/Video/Interview: ___/___/_____
Talent Name: ______Date of Birth: ___ / ___ / ____
Phone: (_____) _____ - ______E-Mail: ______
Address: ______
City: ______ST: _____ Zip: ______
(Please check one of the following)
Staff Volunteer Student Patient Visitor Other: ______
Description of Photo/Video/Interview: ______
______
______
I hereby allow Piedmont Access To Health Services, Inc. (PATHS) to use this photo and/or video and/or interview material for its public relations and marketing purposes. I am waiving all rights to fees and compensation for use, replication, publication, and distribution in future PATHS Manuals, and PATHS Annual Reports, Internet websites, videos, and other such projects.
Signature: ______Date: ____ / ____ / ______
Note: If the individual is under the age of eighteen, we request the authorization of the parent or guardian.
Administrative Use Only:Subject Contact: ______
Organization: ______Phone: (____) ____ - ______
Photographer: ______
Organization: ______Phone: (____) ____ - ______
Permissions needed? Yes No
01-04-010 Use of Patient Image for Marketing or Press Release
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