I hereby irrevocably authorize Peter DeNoble, MD, David Ratliff, MD, and Lorraine Stern, MD of Modern Orthopaedics of New Jersey, LLC, and their employees, agents and assigns, to take photographs and videos of me prior to, during, and after any surgery(ies), procedure(s), or treatment(s) that I have or may receive, for diagnostic purposes and to enhance the medical record.
I agree that these photographs and videos, and any reproductions thereof, shall become and remain the property of Modern Orthopaedics of New Jersey, LLC.
I further authorize the following uses and disclosures of my photographs and videos:
Advertising/Promotional Purposes. I hereby consent to the publishing, reproduction, use or reuse of my photographs, videos, and/or other audiovisual recordings and/or related information, including but not limited to my name, likeness, biographical information, and other information which may identify me to the public in any form of print or media, including the internet, television, newspapers, journals, periodicals, office materials, promotional materials, and other exhibitions or public media for any purpose and for use in publicity, marketing and advertising in all media.
Medical/Scientific Purposes. I hereby consent to the use of my photographs and videos for medical, scientific, education, and research purposes, as deemed appropriate by my physician, which may include, but are not limited to, the publication, reproduction, use or reuse of my photographs and videos in professional journals, medical books, medical/scientific/educational seminars and presentations, or for any other purpose which may deemed proper in the interest of medicine, science, education, knowledge or research.
I understand that I may revoke this authorization, in whole or in part, at any time, except to the extent action has already been taken in reliance upon this authorization. If I revoke this authorization, my revocation must be in writing, signed by me or on my behalf, and delivered to the Privacy Officer at the above-referenced office. My revocation will be effective once received.
I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and will no longer be protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA Privacy Rules).
I hereby release Peter DeNoble, MD, David Ratliff, MD, Lorraine Stern, MD, Modern Orthopaedics of New Jersey, LLC, and its subsidiaries and affiliates, its employees, agents, assigns, officers, and directors, from any and all liability and/or claims of any kind or nature that may result from the taking, printing, publication, retaining, and using of my photographs, videos, audiovisual recordings, and other information obtained in connection therewith. I hereby waive all rights that I may have to any claims for payment of money or royalties in connection with any publication or other use of my photographs, videos, audiovisual recordings, and other information.