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MEDIA AUTHORIZATION FORM INSTRUCTIONS - webmedia unmc

MEDIA AUTHORIZATION FORM INSTRUCTIONS - webmedia unmc 2025

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The Media Authorization Form is a document used by the University of Nebraska Medical Center and The Nebraska Medical Center to obtain consent from patients or their guardians for the use of their images and information in various media formats, including photographs, articles, and videos. It outlines the rights of the individual regarding the use of their information, the ability to withdraw consent, and includes instructions for completing the form.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name and address in the designated fields. Ensure accuracy for proper identification.
Fill in the city, state, and zip code to complete the contact information.
In the 'Description of Information to be released' section, specify what type of media will be used (e.g., photographs, articles).
Indicate any possible air/publication date if applicable.
Select consent options for interview, photography, videotape, or other by checking the appropriate boxes.
The patient or their parent/guardian must read through the authorization statement and sign at the bottom where indicated.
An employee should fill in their name and phone number where it states withdrawal notification.
The employee signs as 'Witness' and dates the form before providing a copy to the patient or guardian.
Retain the original form securely filed by the employee for record-keeping purposes.

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How to fill out HIPAA authorization?

How do I fill out a HIPAA release form? Provide instructions. Name the patient and individual authorized to use or disclose their PHI. Describe the information. Specify recipients. Specify the purpose of disclosure. Specify the time period. Detail their revocation rights. Obtain the patients signature.

How do I give someone a HIPAA authorization?

A HIPAA-compliant HIPAA release form must, at the very least, contain the following information: A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed.

Should I accept or decline HIPAA authorization?

478-Does the Privacy Rule require that an authorization be notarized or include a witness signature. The Privacy Rule does not require that a document be notarized or witnessed.

What is a media authorization form?

Simply put, the media authorization form allows advertising agencies to purchase advertising inventory on a clients behalf. This simple document formalizes the agreement and increases both transparency and accountability between agency and advertiser.