PHOTO RELEASE

Patient’s Name:	 												
				Last					First				Middle

Parent/Guardian Name: 												
			Last					First				Middle

Home Address:												____________

Home Telephone:						     Patient’s Date of Birth:_______________________  

Information Authorized to be Used and Disclosed:  I authorize PR Orthotics & OT, LLC (“the Company”) and others it may authorize to photograph and/or film the patient pursuant to this Authorization.  I also authorize the Company to use and disclose the photographs or film and the patient’s likeness, identity, statements and information about the patient’s health, payment and treatment experience at the Company in any print, broadcast, electronic or other media and in marketing materials pursuant to this Authorization.  

TERM:  This Authorization will be effective for twenty five (25) years from the date signed unless I submit a written notice of revocation to the Company at the address below.  The revocation will be effective immediately upon receipt, except that the revocation will not have any effect on any action taken before receipt of my written notice of revocation.

PURPOSES AND RECIPIENTS:  The information identified above may be used or disclosed under this Authorization only for general publicity and marketing.  It may be received by the general public, professional groups, and media outlets (newspapers, television stations, etc.).  It is also necessary for some insurance claims.
I understand that once the Company discloses information about the patient, they cannot guarantee that the recipients will not redisclose the information to a third party.  Further, the recipients may not be required to abide by this Authorization or applicable federal and Illinois law governing the use and disclosure of patient information.
I understand that I may refuse to sign or may revoke this Authorization at any time for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of the patient’s treatment from the Company.  
I also release, discharge, and agree to hold the Company harmless from any and all claims of any kind which I, my heirs, executors, and assigns may have arising out of or in connection with the Company’s use of the patient’s name, likeness, identity, words or treatment experience pursuant to this Authorization. 
I may contact PR Orthotics & OT, LLC at any time care of Patricia Rogel, Director, 4711 Golf Road, Suite 1055, Skokie, IL  60076-1224.  Or I can call 224-470-8550, if I have any questions about this Authorization or wish to revoke it.
o By checking this box and initialling , I authorize the use of images for insurance purposes only.   ________
I have read and understand the terms of this Authorization and had an opportunity to ask questions about the use and disclosure of information about the patient.  By my signature, I authorize the uses and disclosures of information about the patient as described above.

________________________________________             __________________________            ___________________
Signature of Parent or other 		      Relationship to Patient			Date of 	Signature
Personal Representative (or Patient if of legal age)