Privacy and Authorization Forms

You need to be sure to use the appropriate consent forms and releases provided here to follow Seattle Children’s policies for ensuring confidentiality and safeguarding the privacy of patients, their families and their care providers.

For Patients:

Use the following form (filled out completely) to document appropriate patient consent to release protected health information (PHI) for publicity.

Authorization for Use or Disclosure of PHI for Publicity (includes photos and videos)

Authorization for Use or Disclosure of PHI for Publicity (Spanish)

 

Use the following form (filled out completely) to document appropriate consent for the authorization to release patient health information.

Patient Health Information (includes x-rays, MRI and labs)

Patient Health Information (Spanish) (includes x-rays, MRI and labs)

 

Use the following form (filled out completely) to document appropriate consent for the publication of patient artwork, creative writing and photographs:

Creative Works Consent Form (includes photo, artwork, crafts and creative writing consent)

Creative Works Consent Form (Spanish) (includes photo, artwork, crafts and creative writing consent)

 

For Non-Patients and Staff:

Use the following form (filled out completely) to document appropriate consent for photos, videos or interviews involving adults, including Seattle Children’s employees/hospital staff.

Photo/Video Image Release for Non-Patients

Photo/Video Image Release for Non-Patients (Spanish)

 

For You and Your Crew:

Use the following form with members of the media or contractors who will interview, film or photograph patients. Each member of your crew will need to fill it out completely and sign it.

Confidentiality Acknowledgement for Recording, Filming and Media Interviews