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Photo release form:
PURPOSE OF AUTHORIZATION: CATHOLIC HEALTH INITIATIVES
Attached is an authorization form for use by Catholic Health Initiatives (“CHI”) to obtain
authorization to photograph and/or interview (as defined in the form) a patient or patient family
member at one of its Market-Based Organizations (“MBOs”), visitors, employees, independent
contractors or other persons who may or may not have association with CHI or one of its MBOs.
The form should not be used by a skilled nursing facility or an MBO.
Photographs or interviews of participants that execute this authorization form may be produced,
duplicated, published, used and/or disclosed in any other manner by CHI, one of its MBOs, and/or
either of its subsidiaries, affiliates, providers or any other individuals or entities designated by such
parties.
This form has an optional provision to use in situations where compensation is made to
participants. If compensation is provided, add the following provision as a new paragraph
above the signature lines:
For consideration in the amount of $__________________ _______________________
(Amount) (Insert initials of participant)
If compensation is provided, you will need to replace the second to last paragraph of the
authorization form with the new paragraph below.
In addition, I waive all rights to or conditions on the use and/or disclosure of these photographs and/or interview
material that I may have pursuant to this authorization and for the consideration provided, I further waive any claim
for payment or royalties related to the production, duplication, publication or other use and/or disclosure of such by
CHI, its subsidiaries, affiliates, or any other party involved in the specified use and/or disclosure, now or in the future.
THIS IS A MODEL FORM; HOWEVER, THERE MAY BE ADDITIONAL STATE-
SPECIFIC REQUIREMENTS FOR SUCH AUTHORIZATIONS, HEALTH
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (“HIPAA”) INCLUDING
PRE-EMPTION OR MORE STRINGENT STATE LAWS, WHICH MAY
NECESSITATE REVISION OR FURTHER CUSTOMIZATION OF THE ATTACHED
FORM PRIOR TO ITS’ USE.
For questions regarding use or applicability of this authorization, please call:
� Terri Karsten, Associate Counsel, Provider Operations (859) 594-3008; or
� Lauren Walker, Manager, Communications Services (859) 594-3111.
REMINDER: This form should be reproduced on CHI letterhead.
(This form was updated January 2006 and is HIPAA compliant as of this date for federal law
purposes.)
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