Duke University Health SystemPatient Name:______

Authorization for the Use and/or Disclosure Protected Health Information Medical Record Number: ______

Date of Birth:______

Phone Number:______

I ______, authorize Duke University, Duke University Health System, Private Diagnostic Clinic, and other members of the Duke Health Enterprise identified in its Notice of Privacy Practices (collectively “Duke”) to use or disclose:

To take, produce, or distribute photographs, images, video and/or audio recordings

To participate in interviews or communications

concerning me or my dependent ______and my medical condition or treatment as described -______

that contain my protected health information, including my image or demographic information, e.g., my name, age or diagnosis (collectively “medical information”).

I authorize Duke to use, distribute, reuse, copy, publish, display, exhibit, produce, or license to a third party my medical information in presentations, publications, printed materialor electronic media, including web sites, video, radio, television,or other electronic forms of media as identified below (Please check applicable activity) :

For publications For advertising or marketing

For advertising or marketingFor community or public relations

For training or education, or medical illustrationTo news media

Health fair or community event

Other: ______

I understand that:

I understand that once the medical information and/or materials are released to the public or media Duke retains no control over the use of my medical information once it is disclosed and may no longer be protected by federal or state privacy law.

I will receive no compensation for authorization of the release of the medical information. I also understand that the authorization of the release of my medical information will not in any way affect my health care payment of health care services.

I have read this form and fully understand the contents. I agree to be bound by this authorization form. I acknowledge and represent that I am 18 years of age or older and have the right to contract in my own name or that I am legally authorized to sign this form on behalf of the patient. The expiration date of this authorization will occur upon the last publication or distribution of the medical information.I understand that I may revoke this authorization at any time. I may revoke this authorization, which I must make in writing and send to the appropriate news office (see contact information below). Such revocation shall not affect any disclosures prior to such revocation. I understand I may review or obtain a copy of the medical information that I am being asked to authorize to be used or disclosed at the news office (see contact information below).

______

WITNESSSIGNATURE

______

DATERELATIONSHIP

 Duke Raleigh Hospital
Marketing & Corporate
Communications
3400 Wake Forest Rd.
Raleigh NC 27609 /  Duke University Hospital/DUHS
DUHS News Office
Box 3354 DUMC
Durham NC 27710
or faxed to: (919)681-7353 /  Durham Regional Hospital
Marketing & Corporate Communications
3643 N. Roxboro St.
Durham NC 27704
or faxed to (919)470-8545

4/14/03, 9/22/2009, 6/11/2010

Signed copy to be provided to patient or personal representative.