UTMB HANDBOOK OF OPERATING PROCEDURES

Section 9 Clinical Policies Subject 9.3 Patients’ Rights Policy 9.3.2 Consent to Photograph, Video/Audio Record and/or Televise Patients

04/01/90 -Originated 03/02/09 -Reviewed w/ changes -Reviewed w/o changes University Advancement - Author

Consent to Photograph, Video/Audio Record and/or Televise Patients

Definition

Photography: For the purposes of this policy “photography” will be used to indicate a recording of a patient’s likeness by a number of visual means, including still photography, videotaping, digital imaging, scans and others. Radiographic imaging is not included in this definition.

Policy

General Consent Form for Photography involving Treatment, Payment or Health Care Operations (TPO) Consent must be obtained and specific requirements must be met when taking or producing photographs, recordings, or television productions of UTMB patients. Consent for Photography, Video/Audio Recordings and/or to Televise Patients Form This consent form limits the use of photography to purposes related to treatment, payment and health care operations. The consent form allows for the use of photography in training and educating the workforce within UTMB. For any other education purpose such as presentations given at conferences, UTMB personnel must obtain a patient’s authorization or de-identify the image. Authorization Form for the Use/Disclosure of Photography for purposes other than TPO UTMB must obtain the Authorization for the Use/Disclosure of Photography, Video/Audio Recordings and/or Televised Sessions of Patients Form for the use or disclosure of photography for purposes other than treatment, payment and health care operations. For example, if a patient requests a copy of his/her photograph, UTMB must obtain a signed authorization form prior to releasing the photograph.

Documentation	The use of photography as part of the patient’s treatment process should be documented in the patient’s health record.
Security and Storage	All patient photographs, videotapes and other images will be stored in a secure manner that protects the patient’s privacy. These images will be maintained as defined by IHOP Policies 2.1.4, Records and Information Management Retention and 9.2.13 UTMB Medical Record Policy)

Security and Storage, continued	The images, not stored with the patient’s paper or electronic health record, must be stored in a manner that allows timely retrieval. These images are generally considered source data which is PHI. All PHI will be used or disclosed and destroyed according to the same policies governing other PHI.
Documentation of Abuse and Neglect	Reportable cases of actual or suspected abuse and neglect do not require prior authorization from the patient prior to photographing, videotaping, and other imaging. These images may be submitted to the investigating agency with appropriate authorization or court order.
Research	Photography taken as part of a research protocol must be approved by the Institutional Review Board (IRB). Consent for such images must be incorporated into the patient consent for participation in the research protocol. Furthermore, if photographs are to be disclosed for any purpose or to any outside entity the Primary Investigator (PI) must obtain the research subjects’ authorization which is found within the informed consent document.
Marketing	Written authorization must be obtained from the patient prior to photographing of the patient for marketing or publicity purposes as delineated in IHOP Policy 6.2.17, Use and Disclosure of PHI for Marketing.
Family and Friends	Generally, patient consent is not required for the patient’s family and friends to photograph the patient while receiving treatment at UTMB; however, this is allowed only with the agreement of the clinician and patient (i.e. medically consistent with the patient’s best interest and/or not disruptive of overall patient care), and with the acknowledgement that the individual may be asked to discontinue taping if the clinician deems it necessary. UTMB staff must ensure that the images will in no way include other patients or staff who have not consented to be included in the images.
Disclosure/ Release of Photographs	All requests for disclosures of photographs made for reasons other than treatment, payment or health care operations must be approved by the Health Information Management Department. All releases of photographs made for reasons other than treatment, payment or health care operations require a signed authorization form from the patient or a valid subpoena or court order.
Manuscripts/ Conferences	Written authorization must be obtained from the patient prior to using photographs, if identifiable to a patient, in manuscripts and presentations at conferences and professional organizations external to UTMB, or in any public forum where they may be viewed by unauthorized individuals.
De-identification of PHI/Disclosure	Unless otherwise required by law or for purposes related to treatment, payment and operations, UTMB will not release photographs, videotapes, or other images to outside requestors, or for other purposes without specific authorization from the patient as defined in IHOP Policy 6.2.29, De-Identification of PHI UTMB may determine that images are not PHI, if identifiers of the individual or of relatives, household members of the individual, or employer are removed. If UTMB believes the image cannot be used in any way to identify the patient, the images may be used for outside purposes without patient authorization.
Revocation	As with all patient authorizations for disclosure of protected health information, the patient has the right to revoke the consent for photographing, videotaping, or making other images at any time. UTMB will not be liable for any use of such images prior to the revocation.
Guidelines for UTMB Employees	UTMB or its employees may take or produce photographs, video/audio recordings, and/or television productions of patients under the following guidelines:
Guidelines for UTMB Employees, continued	• The patient must sign a witnessed consent form. • A patient who is a minor or any patient who is unable to sign a consent form must have the form signed by a parent or, as the case may be, a legal guardian. Photographs of offender patients (Texas Department of Criminal Justice, Federal Bureau of Prisoners, Texas Youth Commission, etc.) may be governed by rules of that agency.  Specific permission to photograph, video/audio record, and /or televise an offender patient should be obtained from the respective prison agency.
Guidelines for Media and Other Third Parties	In any instance when the media wishes to interview, film, or record a UTMB patient, the conditions stated in ‘Guidelines for Families and Friends’ must be met; and a representative from the Office of University Advancement must accompany the media for all photographs, films, or recordings. A written request from insurance company personnel, attorneys, etc. to film, record, or televise UTMB patients must be directed to the patient’s attending physician, the nursing director, or medical director. It must include a duly authorized and signed information release document. Such legal release document, must be received prior to obtaining patient/family legal guardian consent of the patient or, , the patient’s parent or legal guardian. The conditions specified in ‘Guidelines for Families and Friends’ apply. Queries may be directed to the Department of Legal Affairs.
References	www.uthscsa.edu/hop2000/11.1.4.pdf IHOP Policy 2.1.4, Records and Information Management Retention IHOP Policy 6.2.0, General Policy on Use & Disclosure of PHI IHOP Policy 6.2.17, Use & Disclosure of PHI for Marketing IHOP Policy 6.2.18 Use & Disclosure of PHI for Fundraising IHOP Policy 6.2.29, De-Identification of PHI IHOP Policy 9.2.14, Medical Record Retention