PACC made the October issue of Business Healthcare Review magazine.
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Patient Consent for Camera
All of our forms are fully HIPAA compliant and are encrypted before sending to provide you with complete security and privacy.
I,
*
consent to be photographed by PURE AUTISM COUNSELING CENTER staff upon admission. These photographs are to remain as part of the permanent medical record and not otherwise disseminated without the patient’s specific consent.
I,
*
have been informed that while a patient at PURE AUTISM COUNSELING CENTER that I will be under camera surveillance for my safety and protection. Surveillance is recording only no audio is included.
It is the policy of PURE AUTISM COUNSELING CENTER that the photo and camera surveillance is for therapeutic purposes and will be conducted upon consent of the patient and only with approved equipment.
Patient First Name
*
Patient Last Name
*
Email
*
Date
*
MM slash DD slash YYYY
