A media consent form is necessary to get explicit permission from any person who is not a student, faculty or staff member at Washington University whose name, likeness or words appears in your group’s communications, promotions or other media. For example, you must get their signed consent in order to use their name, likeness or words in photos, videos, audio recordings and testimonials.
Consent is not required for Washington University students, faculty and staff. As a courtesy, please advise these individuals of the purpose of the shoot or interview.
If you have any questions about the consent process, including acquiring the necessary permission for recording visiting speakers and lecturers, please contact us.
Use the HIPAA media release, and make two copies of the signed form.
HIPAA media consent form
Where to send forms:
- Send original signed release to Medical Public Affairs (Campus Box 8508)
- Keep a copy for your group’s records
- Provide a third copy to the individual
We can send you triplicate forms (white-yellow-pink copies), which make it easy to immediately provide patients copies of their signed form. Contact Theresa Howard (firstname.lastname@example.org), and we’ll send you blank forms through campus mail.
If the communication is unrelated to clinical care, use the general media release form.
Media release form (pdf)
For minors/children: Media release form (pdf)