Photo/Video Permission and HIPAA Authorization Forms

Photo/Video Permission and HIPAA Authorization Forms

Model release forms must be obtained from people you are photographing or videotaping. These forms are required in order to grant an entity permission to use the subject's image in any medium for educational, promotional, advertising, or other purposes. For public events, releases are not required; it is strongly encouraged, however, that model releases are signed by all subjects if at all possible. One form is specifically for minors and must be completed by a parent or guardian.

As a health care provider, Rutgers must protect the privacy of our patients. When capturing images or obtaining other personal information from patients, we are required under the Health Insurance Portability and Accountability Act (HIPAA) to obtain their permission to use the information or images by completing the HIPAA Authorization form (see below).

Model Releases

Department/division, building and room, school, address, and phone numbers can be modified to reflect your office. Other content should not be modified in any way without the assistance of the university counsel.

Download the Releases:

English Español

Model Release Form (DOC)

Permiso Uso Imagen (DOC)

Model Release Form for Minors (DOC)

Permiso Uso Imagen Para Menores de Edad (DOC)

HIPAA Authorization

You must obtain a completed HIPAA Authorization for Use/Disclosure of Information and Consent/Use of Photographs and Audio/Video Images form from patients and/or patient legal representatives who disclose health information to you in any form (e.g., written, electronic, photographs, videos, reports, x-rays, lab results, and verbal) that you intend to use in communications vehicles (e.g., news releases, magazine stories, website content, brochures, advertisements, photos, videos, etc.).

When using the form, you should

  • provide the patient and/or patient legal representative with the form and explain its purpose before interviewing, photographing, or taping begins;
  • have the patient or representative sign the form, date it, and provide the contact information requested;
  • provide a copy of the authorization to the person, if requested; and
  • keep the authorization on file.

Do not alter this form. If you require changes to it, seek assistance from the Rutgers Privacy Officer using our online form.

Download the Form:

HIPAA Authorization Form (PDF)

For additional information or questions, contact:

Jeanne Weber
Director, Creative Services
Phone: 848-445-1934
Fax: 732-445-1906

Department of University Communications and Marketing
Rutgers, The State University of New Jersey
96 Davidson Road
Piscataway, NJ 08854-8062
Location: Davidson Hall, Busch Campus