Patient Name:______Medical Record Number:______Date of Birth:______Phone Number:______

Duke University Health System Authorization for the Use and/or Disclosure Protected Health Information

I ______, authorize Duke University, Duke University Health System, Private Diagnostic Clinic, and other members of the Duke Health Enterprise identified in its Notice of Privacy Practices (collectively “Duke”) to use or disclose: To take, produce, or distribute photographs, images, video and/or audio recordings To participate in interviews or communications concerning me or my dependent ______and my medical condition or treatment that contain my protected health information, including my image or demographic information, e.g., my name, age or diagnosis (collectively “medical information”).

I authorize Duke to use, distribute, reuse, copy, publish, display, exhibit, produce, or license to a third party my medical information in presentations, publications, printed material or electronic media, including web sites, video, radio, television, or other electronic forms of media as identified below (Please check applicable activity) :

For publications For advertising or marketing For advertising or marketing For community or public relations For training or education, or medical illustration To news media Health fair or community event Other: ______

I understand that: I understand that once the medical information and/or materials are released to the public or media Duke retains no control over the use of my medical information once it is disclosed and may no longer be protected by federal or state privacy law.

I will receive no compensation for authorization of the release of the medical information. I also understand that the authorization of the release of my medical information will not in any way affect my health care payment of health care services.

I have read this form and fully understand the contents. I agree to be bound by this authorization form. I acknowledge and represent that I am 18 years of age or older and have the right to contract in my own name or that I am legally authorized to sign this form on behalf of the patient. The expiration date of this authorization will occur upon the last publication or distribution of the medical information. I understand that I may revoke this authorization at any time. I may revoke this authorization, which I must make in writing and send to the appropriate news office (see contact information below). Such revocation shall not affect any disclosures prior to such revocation. I understand I may review or obtain a copy of the medical information that I am being asked to authorize to be used or disclosed at the news office (see contact information below).

______WITNESS SIGNATURE ______DATE RELATIONSHIP

 Duke Raleigh Hospital  Duke University Hospital/DUHS  Durham Regional Hospital Marketing & Corporate DUHS News Office Marketing & Corporate Communications Communications Box 3354 DUMC 3643 N. Roxboro St. 3400 Wake Forest Rd. Durham NC 27710 Durham NC 27704 Raleigh NC 27609 or faxed to: (919)681-7353 or faxed to (919)470-8545

4/14/03, 9/22/2009, 6/11/2010 Signed copy to be provided to patient or personal representative.