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Consent to use patient artwork and photos.
Formulario de consentimiento art en Español.
Use the artwork and artist information of the patient named above (including but not limited to name, age, photos, videos or other images) on www.childrenswi.org, Children's Wisconsin's public displays, exhibits, social media, in our electronic communications, with the news media or in printed materials.
You acknowledge that you understand that this authorization is voluntary and that you may refuse to sign it, in which case Children’s Wisconsin will not use any identifying information as specified in this form.
You acknowledge you have been given a copy of the Children’s Wisconsin's Notice of Privacy Practices which describes the rights of Children’s Wisconsin to disclose patient information.
You acknowledge you are aware that the patient name and the patient status or service line may potentially be viewed and re-disclosed by a member of the public and may no longer be protected by United States or State confidentiality laws.
You will be provided a copy of this form after you submit it and it is accepted by Children’s Wisconsin.
Children’s Wisconsin may not condition treatment on whether this consent form is submitted. This authorization is valid until the patient/child becomes 18 years of age. For patients 18 years old or older, this authorization will continue to be valid until notice of termination from the patient/guardian is received. Authorization may be terminated at any time by contacting ConsentForms@chw.org or calling the Marketing Department at (414) 266-5420.