HIPAA Authorization (Healthcare Clients Only)

Creating Lasting Memories Through Beautiful Photography.

Patient authorization to photograph and use images — used only where a healthcare client requires it.

BTL-PBL-16.032

Form

Vol 16 — Beauty Through the Lens Media Group

Header

Client / Project *

Date *

Prepared by *

Purpose *

Line 1

Line 2

Line 3

Line 4

Line 5

Additional notes

Prepared by *

Signature *

Date *

Prepared by

Name · Title · Date

Reviewed by

Name · Title · Date

Approved by

Owner · Katheryn L. Wilkins · Date

Controlled document — BTL-PBL-16.032. Complete all required fields (marked *). Retain per Volume 15 retention schedule.