Patient Authorization for the Use and Disclosure of Photographs, Video Recordings, Audio Recordings, and/or Other Multi-media Imaging.
I consent to being photographed, video recorded, audio recorded, and or to having other multi-media imaging taken of me (collectively, the “Materials” to be use by Dr. Thanapoom Boonipat and his clinic (‘his clinic’) for identification, diagnosis, and treatment purposes.
I hereby grant permission for the use of any of my medical records including illustrations, photographs or other imaging records created in my case, for use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery, Inc.
His clinic may also use the Materials for education, training, and promotion of his clinic.
I understand that whenever Materials are disclosed to a third party, they may no longer be protected by state and/or federal privacy regulations and may be re-disclosed by the recipient.
I understand that the Materials are Protected Health Information (PHI) that may identify me. I understand that his clinic may take reasonable steps under federal law to remove information about my identity from the Materials. I understand that Materials that are de-identified in this way (collectively, “De-Identified Materials”) are not PHI.
I agree that his clinic may use and disclose De-identified Materials for educational purposes. Education purposes include, but are not limited to, publication in professional journals, registries, brochures, textbooks, online social media, and/or their online equivalents as well as presentations at seminars, symposiums, and continuing medical education conferences. I understand that his clinic cannot guarantee that I will not be re-identified despite the steps taken to remove information about my identity.
I agree that Materials and De-Identified Materials are the sole and exclusive property of his clinic, free and clear of any claim by me, and I shall not receive royalties or other compensation or consideration for the use and/or disclosure of the Materials or De-Identified Materials by his clinic. I release his clinic and its personnel from any and all liabilities which may arise from the use or disclosure of Materials and De-Identified Materials under this authorization.
I understand that this authorization will remain in effect until his clinic fulfills all purposes for using and disclosing Materials and De-Identified Materials as described herein or until I revoke this authorization, whichever occurs sooner. I understand that I may revoke this authorization at any time except to the extent that his clinic has already acted in reliance on it. Revocation must be made in writing to: Thanapoom Boonipat, 12505 Quaker Ave Unit A, Lubbock TX 79424.
I understand that the revocation of this authorization will not apply to Materials or De-Identified Materials that have already been disclosed in accordance with the terms of this authorization. I understand that this authorization will remain in effect unless specifically revoked by me.
I understand that his clinic will not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization.
This is a legal document. Please read carefully. By signing, you agree that you understand and accept the terms on this form.
If the patient is 18 years of age or older, the patient must sign and date the form.
If the patient is 18 years of age or older and is incapable of signing, a legally authorized substitute may sign and date the form. Please indicate your legal authority and included documentation of your relationship:
Legal Guardian or conservator Health Care Agent (Health Care Power of Attorney)
If the patient is 17 years of age or younger the patient’s parent or legal guardian must sign and date the form, unless an exception exists under
state or federal law.
Please indicate your relationship: