Parent/Guardian Consent for Recordings and Use of Likeness of Minor Students

I,______, the parent/guardian of ______(the “Student”) give my permission, as indicated below, for the Student to be video/audio recorded during psychotherapy diagnostic/treatment sessions at the ______(Please print Organization’s name here).

I am consenting to:___ Audio Recordings ___Video Recording/Motion Pictures

(check all that apply)

I consent to the Think:Kids Program at Massachusetts General Hospital using these Recordings and personal information collected during the Recordings, including health information, for (check all that apply):

Education, training, and quality assurance and improvement purposes:

Within Massachusetts General Hospital

Outside of Massachusetts General Hospital but only for purposes of training professionals on the Think:Kids treatment model

Other:

I understand that any or all of the information provided by me, the Student or the Student’s care team during the Recordings may be used and disclosed for the above-indicated purposes, including personal and health information about the Student.

I also understand and agree that:

  • I grant and release to the Hospital all rights, title and interest that I or the Studentmay have in these Recordings, including copyrights in the Recordings and rights to use, reproduce, modify, create derivative works of, broadcast and distribute the Recordings.
  • Participation in the Recordings is voluntary and neither the Student nor I will receive, and we are giving up any claim to receive, any payment or royalties in connection with any use or disclosure of the Recordings.
  • Only individuals who are approved by the Hospital shall conduct or produce the Recordings.
  • If any of the Recordings are given to a third party outside the Hospital, the Hospital cannot control how they will use or share the Recordings.
  • The Recordings may be edited, modified, or retouched to withhold the Student’s identity.
  • The Recordings will not be included in or maintained as part of the Student’s medical record.

I  do  do not authorize the Student’s name to be used in connection with these Recordings.

If the Recordings will be shared outside of the Hospitaland they contain information that could be used to identify the Student (such as: name, face, voice, demographics) and reveal information about my medical conditions or treatment, I must also sign a HIPAA authorization form (See page 2).

Parent/Guardian SignatureDate

Relationship to Student:

Print MGH Staff Representative NameSignatureDate

PLEASE RETAIN A COPY OF YOUR SIGNED AUTHORIZATION FORM FOR YOUR RECORDS

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Parent/Guardian HIPAA Authorization for Release of Protected or Privileged Health Information of Minor

I authorize Massachusetts General Hospital and its affiliates (the “Hospital”) to use and release personal information about ______(the “Student”), including health information, medical history, diagnoses, medical care and treatment, for the following purposes: (check all that apply):

Education and training of health care professionals outside of the Hospital ______

Other:

Authorized Information: I separately consented to the Hospitalmaking video recordings/motion pictures and/or audio recordings of the Studentduring diagnostic or treatment sessions (“Recordings”). The Hospital may use and release these Recordings according to my Parent/Guardian Consent for Recordings and Use of Likeness of Minor Students (attached hereto), and release personal information about the Student, including health information, medical history, diagnoses, medical care and treatment in accordance with such Consent and this HIPAA Authorization. I understand that the Student can be identified from these Recordings and his/her information will no longer be protected by privacy laws once released.

I understand that the Hospital requires my specific authorization to release information about the following counseling/treatment/tests. Checking “Yes” gives the Hospital my permission to release the information. Checking “No” means I do not give my permission to release the information or it is not applicable.

PLEASE RETAIN A COPY OF YOUR SIGNED AUTHORIZATION FORM FOR YOUR RECORDS

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Yes O No OHIV test results, status or counseling/treatment

Yes O No OGenetic Screening Tests Results

Yes O No OTreatment for Alcohol and Drug Abuse. This consent may be revoked upon oral or written request.

Yes O No OMental Health Diagnosis and/or Treatmentby a Psychiatrist, Psychologist, Mental Health Clinical Nurse Specialist, Licensed Mental Health Clinician, or Licensed Social Worker

PLEASE RETAIN A COPY OF YOUR SIGNED AUTHORIZATION FORM FOR YOUR RECORDS

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Yes O No ODomestic Violence Victim’s Counseling

Yes O No OSexual Assault Counseling

I understand that:

  • I may refuse to sign this authorization. This will not affect the Student’s treatment, payment, health plan enrollment, or eligibility for benefits. However, the Student may not be able to participate in the Recordings.
  • I may change my mind and take back this authorizationexceptif the authorized action has already been taken. I understand the Hospital cannot get back copies of the Student’s Recordings and information once they have been released to third parties. Once released to third parties, the Hospital has no control over how the third parties use, disclose or protect the Student’s Recordings and information.
  • To take back this authorization: Write to: ______Fax and phone number: .
  • This authorizationremains in effect until the Student’s Recordings and information are no longer needed for the above-indicated purposes unlessI specify otherwise in the space provided below. I understand that despite the expiration of this authorization, the Hospital cannot prevent third parties who have received the Student’s Recordings and information from continuing to use them. Authorization expires: ______.
  • Regardless of whether I have prohibited the Hospital from disclosing the Student’s name, the Student and his/her medical condition and/or treatment may still be identifiable through the disclosures I have authorized.

I have carefully read and understand this form and have had my questions answered to my satisfaction. I expressly and voluntarily authorize the Hospital to use and disclose the Student’s Recordings information as set forth above:

Name of Parent/GuardianSignature Date

Relationship to Student

PLEASE RETAIN A COPY OF YOUR SIGNED AUTHORIZATION FORM FOR YOUR RECORDS

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