Model Release and HIPAA Authorization Forms
Important information and documentation for getting necessary authorization to capture and use photography or video and disclose medical information on the people you are photographing or recording.
Quick Downloads
Please read and be sure to understand all the information on this page regarding these important documents. In addition to these PDFs, access customizable Microsoft Word versions of model release forms below.
Model Releases and HIPAA Authorization
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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 and identifying information in any medium for educational, promotional, advertising, or other purposes. For public events, releases generally are not required if images do not focus on any individual; however, it is strongly encouraged 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.
Your department/division, building and room, school, address, and phone numbers should be added at the top of the form on either the DOC or fillable PDF. To use the fillable PDF form, download Adobe Acrobat Reader for free. Links to instructions for completing a fillable form can be found below. Other content should not be modified in any way without the assistance of University Communications and Marketing.
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As a health care provider, Rutgers must protect the privacy of patients and individuals disclosing health information. When capturing images or obtaining other personal health information from individuals, 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.
You must obtain a completed HIPAA Authorization for Use/Disclosure of Information and Consent/Use of Photographs and Audio/Video Images form from patients, patient legal representatives, and/or any individuals 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 photographing or videotaping individuals receiving services that are health related, you must obtain a HIPAA Authorization in lieu of a model release. For assistance on which form to use, please contact University Communications and Marketing.
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When using the HIPAA Authorization 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 University Communications and Marketing or the Rutgers Privacy Officer.
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HIPAA Authorization (PDF fill-in form)
HIPPA Authorization - Spanish (PDF)
How to Complete a Fillable PDF
The fillable PDFs can be completed in Adobe Acrobat Reader, which is free to download.
Read Adobe's instructions on how to
Photographing and Filming at Events
While there currently is not a formal policy, it is a good practice to notify your participants in advance and at the start of an event that the session will be recorded and that the content may be distributed or posted elsewhere.
Use this boilerplate text on your event registration forms, program booklets, and event signage.
By attending this event, you agree to give Rutgers University permission to record you and your registered guests’ (including minors under the age of 18) image and/or voice and grant Rutgers all rights to use these sound, still, or moving images in any medium for educational, promotional, advertising, or other purposes that support the mission of the university. You agree that all rights to the sound, still, or moving images belong to Rutgers.
Contact UCM
For additional information, assistance with changing forms, or questions, contact:
Jeanne Weber
Senior Director, Marketing Communications
Phone: 848-445-1934
Department of University Communications and Marketing
Rutgers, The State University of New Jersey
101 Somerset Street
New Brunswick, New Jersey 08901
Location: Alexander Johnston Hall, College Avenue Campus