Model Release and HIPAA Authorization Forms

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 in any medium for educational, promotional, advertising, or other purposes. For public events, releases generally are not required; it is strongly encouraged, however, 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.

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.

Model Releases

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.

Download the Releases:

HIPAA Authorization

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.

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.

Download the Form:

HIPAA Authorization (PDF)
HIPAA Authorization (PDF fill-in form)

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

• Fill in a PDF form
• Sign a PDF
• Save and print the completed PDF form

For additional information, assistance with changing forms, or questions, contact:

Jeanne Weber
Director, Creative Services
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